A MANUAL 



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Clinical tifeofatory 



LIBRARY OF CONGRESS. 

T \3^ 31 

Chap. Copyright Ko. 

ShelfJ&Lfe.?^ 



UNITED STATES OF AMERICA. 



An Introduction 



INTO THE 



LABORATORY METHODS OF 

CLINICAL PATHOLOGY 



EDWARD L. WHITNEY, M. D. 

DEMONSTRATOR OF CLINICAL PATHOLOGY 

AT THE 

BALTIMORE MEDICAL COLLEGE 

(COPYRIGHTED.) 




PUBLISHED BY THE AUTHOR 
1896. ' 



f*M\ 



k-*-' 






Press of 

C. W. Schneidereith & Sons, 

Baltimore. 



Entered according to act of Congress in the year 1896 by Edward L. Whitney in the office 
of the Librarian of Congress, at Washington. 



PREFACE. 



The friendly interest which has been shown by many colleagues and 
on part of a large number of Students in our special course on Diseases 
of the stomach and intestines have caused me to urge upon the author of 
this concise and practical little book — its speedy publication. Dr. Edward 
L. Whitney is eminently qualified for adapting this compend to the needs 
of the student and practitioner alike. His experience as a laboratory 
instructor and hospital physician has guided him admirably to present in 
a condensed and concise form most of the essential and indispensable aids 
to Clinical Diagnosis that are offered by chemistry, bacteriology and the 
technics of the microscope. 

I hope it may stimulate its readers to further study of the literature 
of the modern methods of Clinical Diagnosis, which is the main hope of 
all true Asclepiads, for taking Diagnosis and Treatment entirely out of 
empiricism and founding it upon ascertained facts. May this little volume 
by Dr. Whitney find its way to the studies of many practitioners and 
st udents. 

JOHN C. HEMMETER, M. B., M. D., Ph. D. 



URINALYSIS. 



AMOUNT IN TWENTY-FOUR HOUES. 

The amount of urine excreted in a day depends upon a 
number of factors. In general we may say that the average 
adult male under average conditions excretes about 1500 cubic 
centimetres varying from 1500 to 2000 cubic centimetres per day. 
The female excretes a smaller amount varying from 1200 to 1500 
cubic centimetres per day. 

The amount of urine is increased: 

1. When an increased amount of fluid is ingested as in beer 
drinkers. 

2. When the amount of fluid lost by perspiration is small. 

3. In the so-called phosphatic diabetes. 

4. In hysteria. 

5. In certain of the neuroses. 

6. In diabetes insipidus. 

7. In diabetes mellitus. 

8. In certain forms of chronic nephritis, (especially the 
small granular kidney.) 

The amount of urine is decreased: 

1. When the amount of fluid ingested is small. 

2. When perspiration is profuse. 

3. In acute nephritis and the large white kidney. 

4. In most of the acute fevers. 

5. When a large amount of fluid is withdrawn from the 
system through some other channel as in diarrhoea and dysen- 
tery. 

6. When there is an* exudation going on in the body as 
exudative pleurisy, ascites, etc. 

COLOE. 

The average color of normal urine of specific gravity 1020 
and 1500 cubic centimetres volume for twenty-four hours is straw 
or wine yellow, or a light amber color. It is subject to consider- 
able variation during the day, that passed in the morning being 
usually the highest colored. Even under normal circumstances 
the urine varies from a pale watery fluid to a highly colored 
reddish brown liquid. The pale watery urine is usually of a low 
specific gravity and contains a small amount of coloring matters 
as well as urea and salts. Highly colored urine is, on the 
contrary, usually of a high specific gravity, strongly acid, and it 



6 

contains relatively large amounts of coloring matters, urea and 
salts. Pathologically the urine is subject to very great variations 
of color. Abnormally light colored urine is often found in 
diabetes insipidus and diabete mellitus, in hysteria and in con- 
vulsions, in all of which there is usually polyuria and. the 
deficiency in color is due to the dilution of the coloring matters. 
Light colored urine also is found in diseases of the kidneys which 
increase the amount of urine and at the same time decrease the 
amount of coloring matters excreted. This is most frequently 
found in chronic interstitial nephritis (small granular kindney) 
an in some cases of amyloid degeneration of the kidneys. 

Highly colored urine, approaching red, is most often induced 
by the acute fevers. This is due in part to their concentration 
and in part to the occurrence of abnormal coloring matters. 

ODOE. 

The odor of freshly voided urine is peculiar and slightly 
aromatic. The odor of the more concentrated urines is the most 
pronounced. If the urine becomes alkaline from standing and 
fermentation taking place the odor becomes peculiarly repulsive 
and the odor of ammonia becomes very plainly perceptible. The 
ammonia is due to the decomposition of urea with the formation 
of ammonium carbonate and the putrescent odor is due to the 
decomposition of mucin and other organic material. In diabetes 
the urine often has an odor which has been likened to that of 
hay, by others it is likened to that of violets. In cystitis with 
alkaline fermentation of the urine, the urine often has the 
unpleasant ammoniacal odor when passed. 

Certain drugs impart their odor to the urine to a marked 
degree, the most common of these being cubebs, copaiba and 
sandal- wood. 

TKANSPAEENCY. 

Normal human urine is clear when passed, soon however 
showing a faint cloud, the nubecula, after standing and cooling. 
Placed under the microscope this will show a few leucocytes and 
pavement epithelial cells derived from the mucous membrane of 
the bladder with a small amount of mucous from the genito- 
urinary tract. If strongly acid, the urine may deposit one 
standing a short time and cooling, a reddish precipitate of urates. 
This may be readily cleared up by boiling the urine. 

Alkaline urine is usually cloudy when passed due to the 
presence of the phosphate and carbonate of lime. This may be 
cleared up by adding a small amount of acetic acid, enough to 
render the urine distinctly acid. The urine may be cloudy from 
the presence in the urine of blood, pus or bacteria, these urines 
are not cleared up either by boiling or by the addition of acid. 
Positive proof of the presence of these constituents is afforded by 
the microscope. 



SPECIFIC GEAVITY. 

The specific gravity of normal human urine varies from 1015 
to 1025 with an average of about 1020. Great physical exertion 
and profuse perspiration may increase the specific gravity in 
perfectly healthy individuals to 1035. After excessive drinking 
the specific gravity of the urine may fall as low as 1002. The 
specific gravity of the urine is as a rule high in diabetes mellitus, 
in rheumatism, and most of the fevers. In chronic nephritis the 
specific gravity of the urine is usually decreased, and in general 
in any disease in which the quantity of urine is increased the 
specific gravity falls. The specific gravity is roughly a measure oj 
the amount of solids in the urine. If the specific gravity of a speci- 
men of urine above that of water (1000) be multiplied by the factor 
2.33; the product will be approximately the number of grammes 
in 1000 cc. of the urine. As solutions of the different constituents 
of urine, of the same strength, have different specific gravities, 
it follows that this is only a rough working formula for the 
determination of the amount of total solids. The estimation of 
the specific gravity of urine is made by means of an instrument 
called the urinometer. This must be carefully constructed and 
graduated to register at a certain temperature. The cheaper 
urinometers are not graduated in this way, so that a good test 
of the accuracy of a urinometer is to notice whether it is graduated 
for a certain temperature. The urine is usually to be tested at 
a temperature of about 60 degrees F. and in no case must be tested 
while it is still sensibly warm. To avoid error the urine should 
be clear and should be poured into the urinometer carefully so 
that no bubbles are formed to interfere with the proper reading, 
Set the urinometer in a perfectly level position so that it does 
not touch the sides of the cylinder. Then place the eye on a 
level with the upper surface of the urine and read the specific 
gravity from the graduation opposite the lower border of the 
meniscus. 

REACTION. 

Normal urine has commonly a marked acid reaction to 
litmus, but after meals the urine may have a decided alkaline 
reaction. The acid reaction of the urine is probably due to the 
presence of acid sodium phosphate, produced by the reaction of 
the uric and sulphuric acids produced by metabolism on the basic 
sodium phosphate existing in the blood, hence it follows that the 
acidity of the urine is increased by exercise and the consumption 
of albuminous foods as also by the ingestion of mineral acids. 
The urine of a person living mainly on a vegetable diet is often 
distinctly alkaline. 

The alkalinity of the urine may be due to the fixed alkalies, 
carbonates and phosphates of the alkali-metals or to volatile alkali 
ammonium carbonate. Ammonium carbonate is formed by the 
decomposition of urea and the determination of the form of alkali 
is made by moistening red litmus paper with the urine and 



8 

drying. If the alkalinity is due to fixed alkali the color is per- 
manent but if due to ammonia the blue color fades as the paper 
dries. 

The degree of acidity may be determined by diluting the 
urine (10 cc.) with distilled water (making up to about 50 cc.) 
adding a drop of phenol-phthalein and titrating with deci-normal 
caustic soda. When the urine is completely neutralised the fluid 
becomes of a faint pink tinge. The average amount of caustic 
soda solution required is about 3 cc. This may be stated as 
caustic soda or it may be expressed as oxalic acid, Each cubic 
centi-metre of soda solution represents an acidity equal to 0.63 
G-m. of oxalic acid in 1000 cc. of the urine. If alkaline the 
alkalinity may be stated in the same way, substituting instead of the 
caustic soda solution, a decinormal-solution of sulphuric acid and 
titrating until the pink color of the phenol-phthalein disappears. 
The mixed secretion of the twenty-four hours should be deci- 
dedly acid. 

ALBUMEN". 

Under certain abnormal conditions any of the four proteids 
of the blood; serum-albumen, serum-globulin, fibrin and haemo- 
globin may appear in the urine. By far the most common one to 
appear is the serum-albumen. Egg-albumen may appear in the 
urine after ingestion of an excessive amount of egg-albumen in 
the food, as may certain of the products of the proteids such as 
proto, hetero, and deutero-albumose. 

Albumen may appear in a number of marked conditions. 
The cause of albuminuria are classified as follows by Purdy : 

1. Disease of the kidney substance. 

2. Alterations in the blood. 

3. Alterations in blood pressure. 



DETECTION OF ALBUMEN". 

All urine which is to be tested for albumen must be rendered 
faintly acid by the addition of acetic acid unless already so. Then 
filter the urine until perfectly clear. 

1. Fill a small test tube nearly to the top with the suspected 
urine and boil. If albumen is present a cloud will form, even, 
if albumen is present in large amount, coagulating in large flakes, 
and, in cases where the amount is very large, coagulating 
completely. This may be due to an excess of the phosphates, 
which are easily differentiated by the addition of a few drops of 
dilute Nitric acid. If the cloudiness is due to the precipitation 
of the earthy phosphates, the precipitate will clear up immediately 
upon the addition of the acid while albumen will be thrown down 
in a more evident precipitate than before. This test while not 
very delicate, will detect albumen when present in anything more 
than a trace. To render the test more exact, two test tubes may 



be taken and one boiled while the other is kept for comparison. 
A faint cloudiness is much easier to detect in this way, Or the 
urine may be boiled only at the upper part of the tube. 

PUKDY'S TEST. 

To a small test tube nearly half filled with urine about 4 cc. 
of a 5f solution of potassium ferrocyanide is added and the fluid 
shaken, after which about one cubic centimetre of acetic acid is 
added. Any precipitate which may form is albumen and nothing 
else as no reaction occurs with mucin, peptones, urates, phosphates, 
alkaloids or resin acibs. 

HELLER'S LAYER TEST. 

A small amount of concentrated nitric acid placed iu a 
small test tube, over this a layer of the filtered urine is placed 
by allowing it to flow slowly down the side of the test tube 
which, if properly done, will leave the urine and acid distinct. 
If albumen is present, a zone of coagulated albumen will form 
at the junction of the two fluids. This zone forms at once if 
there is a large amount of albumen present. When present in 
very small traces it may not become apparent for some little time 
so that in case of doubt, the test tube should be set aside for 
about five minutes before deciding that albumen is absent. If 
carefully applied this test is capable of detecting 1 part in 30,000, 
and is delicate enough for all practical purposes when carefully 
done. 

TANRET'S REAGENT. 

This reagent is prepared by the following formula: 
Potassium Iodide 3.32 Gm. 
Dissolve in 20 cc. of distilled water. 
Mercuric Chloride 1.35 Gm. 
Dissolve in 44 cc. of distilled water. 
Mix and add 32 cc. of acetic acid. 

This may be used as a layer test or by adding equal amounts 
of urine and the reagent. This reagent precipitates mucin, pep- 
tones and alkaloids but these substances are cleared up on boiling 
while albumen is not. It will detect 1 in 100,000 according to 
some authorities. 

QUANTITATIVE ESTIMATION. 

The amount of albumen may be estimated quantitatively by 
means of the Esbach albuminometer. This is a tube graduated 
for certain percentages of albumen by experiment. It is filled to 
the mark U with urine and the reagent then added to the mark 
R. The tube is then inverted gently a few times (about 12 
times) without allowing any bubbles to become mixed with the 
albumen and set away in a level place for 24 hours. At the end 



10 

of this time the percentage of albumen is read off. Each division 
represents 1-10 per cent of albumen, or each division represents 
one gramme of albumen in 1000 cc. of urine. This instrument 
is only divided from 1 to 7 so that if the percent is above 7 the 
urine must be diluted one-half. If the quantity is below 1-10 per 
cent the instrument can not be used. 

The most accurate way of estimating the amount of albumen 
is by precipitating the albumen by heat and acetic acid, and 
weighing the precipitate after drying for several hours at a 
temperature of 100 degrees C. The acid must be added a little 
at a time, boiling and filtering between the addition of the acid 
until the filtrate yields no precipitate by any of the albumen 
tests. 

TITRATION METHOD. 
Two solutions are required: 

1. A standard solution of mercuric chloride 10 grammes in 
1000 cc. of distilled water. 

2. A 5$ solution of potassium iodide. 

Method: In a small flask place 5 cc. of the potassium iodide 
solution and a few drops of acetic acid. Add to this the mercuric 
chloride solution, drop by drop, until a distinct red tint appears. 
Place in the flask 10 cc. of the urine to be tested and again run 
in the solution of mercuric chloride until the red color which 
disappears in the presence of albumen again appears. Each cubic 
centimetre required for the second titration is equivalent to 0.0245 
grammes of albumen. This test is based upon the fact that 
mercuric chloride in the presence of albumen and potassium iodide 
reacts first with the albumen and when all the albumen has been 
precipitated, reacts with the potassium iodide to form the red 
iodide of mercury. 

GLOBULIN. 

Globulin occurs in the urine quite frequently, usually with 
the presence of albumen at the same time. It is precipitated by 
the same reagents as albumen, and may be separated from that 
body by its insolubility in a saturated solution of Magnesium 
Sulphate. 

DETECTION. 

Twenty cubic centimetres of the urine is fully saturated with 
Magnesium Sulphate and filtered. The precipitate is washed with 
a saturated solution of Magnesium Suphate. Re-dissolve the 
precipitate in distilled water and on boiling the acidulated solu- 
tion there will be a precipitate of the globulin. To estimate it 
quantitatively a larger quantity of the urine must be taken, and 
the second precipitate (that produced by boiling) weighed after 



11 

thorough drying. Or better still than weighing is the estimation 
of the amount of globulin by the amount of ammonia evolved and 
and titrated by the Kjeldahl method. 

Albumen and globulin usually occur together and in variable 
proportions, but in general terms it may be stated that the greater 
the proportion of globulin the graver the prognosis. 

SUGAR 

Sugar appears in the urine in two conditions, 1, as a tem- 
porary condition in which the excretion of sugar is due to the 
ingestion of an excessive amount of carbohydrates, to some nervous 
affection or to the ingestion of some drug such as chloroform or 
nitrite of amyl, etc., and 2, as the true diseased condition known 
as Diabetes Mellitus. 

This disease is usually but not always attended by the passage 
of a large amount of urine (polyuria). In typical cases of this 
disease, the volume of urine excreted reaches from 3000 to 4000 
cc. and may reach as high as 12,000 cc. per day. Typical diabetic 
urine is usually pale, but in mild cases not accompanied by 
polyuria the urine may be normal in color. The odor may 
resemble that of hay, and in advanced cases may give the odor 
of acetone or alcohol. The urine shows a marked tendency to 
froth when shaken and the froth is quite persistent. Its reaction 
is usually acid even after the administration of alkalies and may 
be extremely acid. The specific gravity of diabetic urine is high ; 
averaging from 1035 to 1040. A case is on record in which the 
specific gravity Was 1074 and the lowest density I have ever seen 
personally was 1024. 

The quantity of sugar varies from a mere trace to as much 
as 600 grammes per day. The percentage of sugar also varies 
widely at different times in the day, being the least in the 
morning and greatest from three to four hours after a meal. In 
making a quantitative test therefore, the mixed twenty-four hour 
urine should be taken. 

Dextrose is the most frequent form of sugar to occur in the 
urine, but lactose, maltose, sucrose or cane sugar, dextrin and 
inosite, other carbo-hydrates may occur in the urine. 

TESTS. 

One of the simplest and most reliable qualitative and quanti- 
tative tests for sugar is the fermentation test. This may be applied 
in two ways, the differential density method or by estimation of the 
amount of gas evolved. 

The differential density method is employed as follows: The 
specific gravity of the specimen of urine is taken, then to about 100 cc 
in a bottle, add a small amount of yeast and allow to stand for about 



12 

twenty-four hours at the ordinary room temperature. At the end of 
this time the specific gravity is again taken and compared with the 
original specific gravity. Each degree lost corresponds to one grain 
of sugar to the fluid ounce, or the percentage of sugar may be obtained 
by multiplying the number of degrees lost by .23. 

In Einhorn's saccharometer the amount of sugar is estimated by 
the amount of C0 2 evolved. If the amount of sugar is small, take 
ten cubic centimetres of the urine, add to it a small amount of yeast, 
free from sugar, shake together well and fill into the saccharometer 
until the long arm is entirely filled. Set away in some warm place 
for twenty-four hours, and then read off the percentage direct from 
the graduations on the tube. If the amount of sugar is large, two 
dilutions should be prepared, 1:5 and 1:10, and treated as above. If 
there is any doubt as to the purity of the yeast a blank test should 
be performed, using pure water, in this way testing for the presence 
of sugar in the yeast. 

Tkommer's Test : If urine or other liquid containing sugar be 
treated with sufficient of a solution of copper sulphate to render the 
liquid greenish, and a solution of caustic soda or caustic potash then 
added, a deep blue liquid will be formed if the urine contain a 
notable amount of glucose. On allowing the solution to stand for 
some hours in the cold, a yellow precipitate of cuprous hydroxide, or 
a reddish precipitate of cuprous oxide will form. This precipitate 
will take place immediately on boiling. 

Bottger's Bismuth Test : The suspected urine is treated with 
an equal amount of caustic soda or caustic potash solution, a 
small amount (as much as will lie on the point of a penknife blade) 
of bismuth subnitrate and then boiled. If sugar is present, the 
bismuth will precipitated as the black metallic bismuth. In the 
presence of albumen this will give a black precipitate of the sulphide 
of bismuth, therefore albumen must be removed before this test is 
applied. 

Picric Acid Test: Mix equal volumes of a cold saturated 
solution of picric acid and caustic soda solution and boil. Then 
add the urine to be tested and boil again for a minute or two. If 
sugar be present the solution will change color from a bright red 
to an intense brownish red, which becomes opaque in the presence 
of more than a trace of sugar. Uu fortunately, creatinin gives a 
very similar color, normal urine giving a blood-red color which 
deepens on boiling. 

Phenyl-hydrazine Test: 50 cc of the urine, free from 
albumen, is treated with two grammes of sodium acetate and one 
gramme of phenyl-hydrazine and boiled for half an hour. When 
cool, the phenyl-glucosazone which is formed, separates either as 
characteristic yellow needle-shaped crystals or as amorphous masses. 
In case it separates as amorphous masses, dissolve in hot alcohol, 
dilute with water, boil to expel the alcohol, and after cooling the 
crystalline deposit will form, which may be recognized under the 
microscope. 



13 

FEHLING'S SOLUTION. 

Slightly acidulate and boil to precipitate albumen if present. 
Then add a few grains of sodium carbonate to render the urine 
distinctly alkaline and boil to precipitate the earthy phosphates. 
Filter. 

Fehling's Solution : (a) 34.64 grammes of pure sulphate of 
copper free from iron and moisture is dissolved in 500 cc of warm 
distilled water and filtered. 

(V) 180 grammes of Eochelle salts are dissolved in about 300 cc 
hot water, filtered if necessary, and 70 grammes of good caustic soda 
or 100 grammes of caustic potash added to it and the solution made 
up to 500 cc. 

Mix equal parts and the solution is ready for use. To avoid 
doubt from the presence of some other reducing substances it is 
best to treat the urine in the following manner: 

To about 8 cc of the urine add 5 cc of the copper solution used 
in making up the test, after a preliminary boiling. Filter. _ Add 
to the filtrate 5cc of the alkaline tartrate solution and boil for 
fifteen or twenty seconds. 

If the solution has been kept for some time it may be tested 
by mixing equal parts (a) and (b) and adding an equal bulk of 
water and boiling. If there is no precipitate the solution is fit 
for use. 

In ordinary cases it is sufficient to mix equal volumes of (a) 
and (b) and boil. While boiling add the urine drop by drop and 
if there is sugar present, it will be shown by a precipitate of the 
red cuprous oxide. Care must be taken that not more than an 
equal volume of urine is used to the original volume of the 
Fehling's solution. 

QUANTITATIVE DETERMINATION. 

By Fehlixg's Solution: A fairly accurate estimation of 
sugar may be made in the following manner; take 10 cc, of a 
freshly prepared Fehling's solution and dilute with 40 cc of distilled 
water and bring to boiling in a porcelain dish. Dilute the urine 
with from five to ten times its volume of distilled water and place 
in a graduated burette. Add the urine gradually to the copper 
solution, which is kept gently boiling until the blue color is 
entirely discharged. When this point has been reached stop the 
addition of the urine and note the exact amount of urine that has 
been used. This amount of urine contains .05 grammes of sugar. 

INDICANURIA. 

Indican occurs in the urine in the form of indoxyl-sulphate of 
potassium. It is a product of the action of putrefactive organisms 
in the intestine upon the proteids of the food, and in rare cases 
it is due to the presence in the body and absorption of decom- 
posing pus. It is associated with impaired motility and paralysis 
of the intestine. The amount of indican formed and eliminated 



14 

is increased in sub- or an-acidity of the gastric juice, resulting 
doubtless from the fact that the food is not subjected to the action 
of a gastric juice, strongly acid enough to prevent the entrance of 
a large number of putrefactive organisms into the intestines. 
Clinically, then, it is increased in diarrhoeas acute and chronic, in 
typhoid fever, in intestinal obstruction, in peritonitis, in gastritis 
acute and chronic, in gastric caucer, in cases where there is a 
large amount of pus retained in the body, and also in some cases 
of malignant disease. 

Test : In a good sized test tube place 5 cc of urine and an equal 
amount of hydrochloric acid, two or three drops of a solution of 
sodium or calcium hypochlorite or a single drop of hydrogen per- 
oxide and about 1.5 cc of chloroform and shake thoroughly, and 
fiually allow to settle. If indican is present in excess, the chlo- 
roform is colored a deep blue, the intensity of the color being a 
fair index of the amount of indican in the urine. Unfortunately, 
there is no easy quantitative test for indican, and the amount 
therefore is best made comparative by always taking the same 
quantities of the reagents and estimating the amount by the 
intensity of the color produced. 

EED INDIGO OR UEEHODIN. 

Eed indigo or urrhodin appears under the same conditions as 
indican and appears to be a modification of the same coloring 
matter, probably an oxidation product. 

Test: Treat the urine as given for ordinary indican as above, 
and instead of the blue color given by ordinary indican, the color 
will be red, the intensity being in proportion to the amount of 
the substance present. (2.) Boil the urine and while boiling add 
a few drops of nitric acid, boiling while the addition is going on. 
If indigo red is present, the urine will turn a deep red. On 
shaking the urine after this boiling, the foam will have a bluish- 
red color. 

Care must be taken to exclude the presence of iodine. If 
present, this will impart a carmine tint to the chloroform, and 
even in the presence of indican will obscure the tint of the indican, 
or exactly simulate the tint of indigo red. The history of the 
patient will clear up this point, or the chloroformic extract may 
be evaporated to dryness and the residue may be tested for iodine 
by means of a weak starch solution. 

CREATINE. 

Creatinin is a normal constituent of urine, the amount present 
in twenty-four hours varying from 0.5 to 4.9 grammes, according to 
the amount of proteids eaten. The proportion is not decreased by 
fasting, but is said to be increased in typhus, typhoid and inter- 
mittent fevers, in pneumonia and tetanus. 

It is diminished in convalescence from acute diseases, anaemia, 
chlorosis and phthisis. 



15 

ISOLATION. 

Liebig's Method : The urine is exactly neutralized with milk 
of lime, and calcium chloride added as long as there is a precipitate 
of calcium phosphate. This is then filtered off and the filtrate, 
which should be neutral or faintly acid, is evaporated to a small 
bulk and the crystals of salt, etc., removed by filtration. 

Thirty-two parts of the filtrate are then treated with one part 
of a very concentrated solution of zinc chloride and the whole 
allowed to stand for some days. The creatinin zinc chloride is 
washed with a little cold water and then with alcohol. It is then 
boiled with freshly precipitated lead hydroxide, the filtrate evap- 
orated, and the residue digested with absolute alcohol, which 
dissolves the creatinin, leaving any creatine insoluble. 

2) When a solution of picric acid is added to a solution 
containing creatinin and a drop of caustic soda solution is added 
to the mixture, which must have been well shaken previously, a 
a deep red color developes which is intensified by boiling. The 
intensity of this tint can be used as a rough quantitative test for 
creatinin. If creatinin is present in marked excess, the solution 
may become nearly black. This reaction will detect creatinin in 
solution when present in the proportion of 1 in 3000. 

Sugar gives the same color with the solution, so this test is 
valueless for creatinin in the presence of sugar. 

UEOPHEN. 

Urophen is considered by some authors to be only a mixture 
of the various coloring matters of the urine and the following 
test to be only a test for the total coloring matters of the urine. 

Test: Four cubic centimetres of the urine are placed in a 
strong test tube and an equal amount of strong sulphuric acid is 
dropped into the urine and shaken. 

In the presence of a normal amount of urophen the solution 
will acquire a deep brown color, which is transparent. In excess 
the color will be nearly black and not transparent. When sub- 
normal the solution turns brown, often having a slight pink tinge. 

Care must be taken in this experiment, for a great deal of 
heat is evolved and the tube is apt to break. To avoid risk it is 
better to do this test over the sink, using a test tube holder. 

UROERYTHEIK 

Uroerythrin is the coloring matter of some of the pink urates. 
It occurs in excess in acute rheumatism and probably in some 
other acute diseases. 

It may be extracted from the pink urate deposit by boiling 
alcohol. The residue after evaporation gives a green color when 
treated with caustic alkalies. 

When in marked excess it may be detected by adding a drop 
of a solution of lead acetate to the urine in a clean test tube, and 
if in excess the precipitate which is produced will have a pink 
tinge, instead of the slightly yellowish tinge of normal urine. 



16 

UREA. 

Urea is in warm blooded animals the main excretory product 
of nitrogenous metabolism. The amount varies quite widely, with 
the amount and kind of food, but is only slightly increased by 
exercise. By the action of the micro coccus ureae it is converted 
into ammonium carbonate, this being the cause of the alkalinity 
of urine after standing for some time in the air. It forms crys- 
talline compounds with the stronger acids when they are added 
to a concentrated solution of urea. The nitrate is formed by 
evaporating urine to about one-fourth its volume and then adding 
nitric acid in excess, urea nitrate separates out, the fluid can be 
poured off and the urea nitrate strained out through muslin. The 
other salts are formed in a similar manner. If a pure product is 
desired the crystals may be purified by recrystallization from 
water, after filtration through animal charcoal. Urea may be 
separated from these compounds by the addition of barium car- 
bonate in excess, and enough alcohol to form a pasty mass. Dry 
on the water bath, extract with alcohol, filter, evaporate the filtrate 
on a water bath, and set aside to crystallize. This is best decol- 
orized by filtration through animal charcoal and recrystallization 
of the filtrate. 

Estimation: Several methods have been devised for the esti- 
mation of urea. The simplest one is by the action of the alkaline 
hypobrpmites and measurement of the amount of nitrogen evolved. 
This is best done in the Doremus ureaometer. The following- 
reagents are necessary: 

1) A solution of 100 grammes of pure caustic soda in 250 
cubic centimetres of distilled water. 

2) Puke Bromide : For use the solution is made as follows : 
one cubic centimetetres of bromine is added to ten cubic centi- 
metres of the soda solution and diluted with ten cubic centimetres 
of water. This mixture is placed in the ureaometer so that the long 
arm is completely filled. By means of the accompanying pipette, 
exactly one cubic centimetre of the urine is allowed to rise through 
the hypobromine solution in the long arm and the instrument set 
aside for fifteen minutes to allow the complete evolution of the 
nitrogen. At the end of this time, the amount of urea may be 
read off from the graduations on the side of the instrument. 
Each graduation corresponds to 0.001 gramme of urea in one cubic 
centimetre of the urine. The so-called percentage is found by 
moving the decimal point two places to the right. The amount 
in 1000 cubic centimetres is found by removing the decimal point 
three places to the right. The amount in twenty-four hours is 
found by multiplying the number of cubic centimetres by the 
amount of urea in one cubic centimetre. For various reasons the 
results found by the hypobromite test never correspond fully with 
the amount of nitrogen which theoretically should be found. It 
has been found from work on pure solutions of urea that from 
88$ to 94$ of the urea is shown by the amount of nitrogen 



17 

evolved. The percentages are slightly higher when working on 
diabetic urine, and on urine to which glucose has been added. 

The other tests are more complicated and not more accurate, and 
so are omitted, but may be found in any of the standard text books. 

URIC ACID DETERMINATION. 

25cc of urine is treated with an excess of ammonium 
chloride (about eight grammes being necessary) add ammonia 
until alkaline and allow to stand for about ten minutes, filter and 
wash with a cold saturated solution of ammonium chloride. Treat 
the precipitate with 20cc of a deci-normal solution of hydrochloric 
acid, boil for some minutes, cool, dilute to 200cc, add a few drops 
of methyl-orange and titrate with 1-10 normal caustic soda. 

The difference between the amount of acid used and the amount 
of caustic soda represents the ammonia of the ammonium urate. 

Each cc of the 1-10 soda solution shows the presence of 
0.0168 gramme of uric acid. 

If time is not essential, it is better to add the ammonium 
chloride and allow to stand for two hours, in which case the 
addition of ammonia is unnecessary. 

The normal amount excreted is about .555 gramme, for the 
average man weighing 66 kilos. 

It is much increased in rheumatism, fevers in general, and in 
that state called lithsemia, uric acid diathesis, etc., corresponding 
to the latent gout of English writers. 

Total Nitrogen: The total amount of nitrogen is best esti- 
mated by the Kjeldahl method. This method is based upon the 
fact that nearly all nitrogenous bodies yield up their nitrogen in 
the form of ammonia when treated with concentrated sulphuric 
acid. Urea and uric acid readily undergo this change, and albu- 
men after prolonged treatment, and passing through several inter- 
mediate stages finally is transformed into ammonia. 25cc of the 
urine is treated with lOcc of strong sulphuric acid in a porcelain 
basin, and boiled gently until reduced to about lOcc and the fumes 
of sulphuric acid are evolved. The residue is then placed in a 
pear-shaped digesting flask, the dish being rinsed with a few drops 
of water. Place the flask in an inclined position to prevent loss 
from spurting, and boil until frothing ceases. If the frothing is 
excessive, a small bit of paraffin may be added. After frothing 
has ceased, add about five grammes of potassium sulphate and 
boil until the solution is perfectly clear or only faintly yellowish. 
Allow the contents of the flask to cool and add about 20cc of 
water, cautiously. Prepare a concentrated solution of caustic soda 
and add slowly until the acid is nearly neutralized. This may 
now be treated in two ways. By the original Kjeldahl method, 
an excess of caustic soda is added to decompose the sulphate of 
ammonia and the whole mixture distilled, the ammonia collected 
and estimated by standard acid. 

Or, the process may be modified by diluting the solution after 
nearly neutralizing it to lOOcc and estimating the nitrogen by the 
hypobromite method. 



18 
CHLORIDES. 

The chlorides in urine are best estimated by the following 
volumetric method. For this the following solutions are necessary : 

1) Pure nitric acid Sp. Gr. 1,200. 

2) Concentrated aqueous solution of ferric ammonium sulphate, 
free from ous salt and from chlorine. 

3) Silver nitrate solution, 29.075 grammes to 1000 cc. 1 cc equals 
0.01 ISTaCl. 

4) Ammonium sulphocyanate, 25 cc of which equals 10 cc of 
the silver solution, or 1 cc equals 0.004 gramme of sodium chloride. 

Method : lOcc of the urine, 50 cc of distilled water, 4 cc of the 
nitric acid, and 15 cc of the silver solution are placed in a 100 cc 
flask and well shaken and finally filled to the 100 cc mark. Filter 
through dry paper and take 80 cc for titration, which is equivalent 
to 8 cc of the urine. 5 cc of the ferric salt is now added, and the 
mixture titrated with the sulphocyanate solution till a red color 
appears, due to the formation of the sulphocyanate of iron. The 
quantity of sodium chloride in 1000 cc of the urine may be calculated 
from the following formula: x equals the amount of ammonium sul- 
phocyanate solution used; then 37.5 minus x, multiplied by .004 
equals the amount of sodium chloride in the amount of urine 
taken (8cc), and from this the amount of the total chlorides is 
found by dividing by eight and multiplying by the number of cc 
passed in twenty-four hours. 

The amount of chlorides excreted in the healthy adult varies 
from 10 to 16 grammes in the twenty-four hours, depending a 
great deal, however, on the diet of the individual. The excretion 
of the chlorides is diminished in all febrile states, and especially 
when attended with a serous exudation. A continued increase in 
the amount of chlorides excreted in the fevers, therefore, is an 
evidence of improvement. Their entire absence, therefore, in such 
a disease as pneumonia renders the prognosis grave. 

PHOSPHATES. 

The phosphates may be estimated approximately by adding to 
the urine (about ten cubic centimetres) about one-third its volume 
of magnesia mixture. There is immediately formed a white pre- 
cipitate of ammonium, magnesium phosphate and of calcium 
phosphate. If normal in amount, there is a milky appearance ; if 
deficient, there is only a slight turbidity, and if in excess, there is 
a heavy creamy precipitate. When accurate results are desired the 
best method of estimation is as follows: 

Method : In an Erlemyer flask place 25 cc of the urine and 
add to it fifteen cubic centimetres of strong nitric acid (1.4). 
Bring to a boil and add, drop by drop, a saturated solution of per- 
manganate of potash until there is a slight permanent precipitate 
of manganic oxide. Remove from flame and add about 1-30 
gramme of white sugar to clear up the precipitate, boiling the 
solution again after the addition of the sugar. Remove from the 



19 

heat and add 13 cc of strong ammonia (.90). Insert a thermometer, 
bring to a temperature of 85 °c, and add 50 cc of the molybdate of 
ammonia solution, wrap in a towel, cork and shake -vigorously for 
five minutes. 

At the end of five minutes filter on asbestos, wash with dis- 
tilled water, and turn into the original flask. 

Add 30 cc of the caustic soda solution and about 1 cc of phenol 
phthalein solution and finally titrate back with nitric acid solution. 
Each cubic centimetre of the alkali in excess of the acid used 
represents 0.001 grammes of P 2 5 . 

Solutions Needed : 1) Mtric acid (1.4). 

2) Ammonia (.90). 

3) Caustic soda solution, made up by taking 323.7 cc of a 
normal caustic soda solution and making up to 1000 cc. 

4) Nitric acid equivalent to the solution of caustic soda. 

5) Molybdate of ammonia solution, made by taking 90 grammes 
of ammonium molybdate, and dissolving in slightly less than 
1000 cc of distilled water, allow to settle, decant, and dissolve the 
residue in ammonia, add to the solution and finally make up to 
1000 cc. Each cc will precipitate .003 grammes of P 2 5 . 



SULPHATES. 

100 cc of the urine is boiled with 5cc of strong hydrochloric 
acid (free from sulphates) and 5cc of a 10$ solution of barium 
chloride. The boiling must be kept up for at least an hour. At 
the end of this time the urine is filtered through a fine, close 
filter and washed with boiling distilled water. Ignite in a weighed 
porcelain crucible to a white ash. After cooling, weigh. The 
.difference in weight will represent the weight of barium sulphate 
formed from the sulphates of the urine. The amount of sulphur 
trioxide in 1000 cc may be found by multiplying the weight of 
barium sulphate found by the factor 3.4333. 



VOLITMETKIC METHOD. 

Solutions Eequieed: Solution of barium chloride (crystal- 
lized) 30.5 grammes in 1000 cc of water. 
Solution of potassium sulphate 20$. 
Pure hydrochloric acid. 
One hundred cubic centimetres of the urine is treated with 

5 cc of hydrochloric acid and brought to the boiling point in a 
flask. The barium solution is then dropped into the flask as long 
as there is a precipitate formed, the mixture being heated before 
each addition of the barium solution. After adding about 5 or 

6 cc of the solution allow it to settle and draw off a few drops of 
the clear solution above and test with a few drops of the barium 
solution. If any precipitate occurs, return the whole to the flask 
and add a small amount of the barium solution as before, allow 
to settle and test as before. The end of the reaction is reached 



20 

when the drop of clear fluid removed gives no precipitate with 
the barium solution and just gives a faint trace of cloudiness on 
the addition of a drop of the potassium sulphate solution. 

Each cc of the barium solution required represents 0.01 
gramme of sulphuric acid. 



ESTIMATION OF PREFORMED SULPHATES. 

Method : 100 cc of clear filtered urine is mixed with an equal 
volume of an alkaline barium chloride solution (two volumes of 
barium hydrate solution and one volume of a barium chloride 
solution, each saturated at the ordinary temperature) strongly 
acidified with acetic acid and stirred thoroughly for several 
minutes. This is then filtered, the precipitate washed with dis- 
tilled water incinerated to a white ash and weighed. This will 
give the amount of preformed sulphates, the sulphuric acid in 
combination with sodium and potassium. The difference between 
the total sulphates and the preformed sulphates will give the 
amount of ethereal sulphates, the sulphuric acid in combination 
with phenol, indoxyl and skatoxyl. These are products of intes- 
tinal putrefaction and are increased in diseases with increased 
intestinal putrefaction. The normal relation between preformed 
and ethereal sulphates is 10-1, but the ratio may fall immensely 
in such troubles as intestinal obstruction. 



BILE PIGMENTS. 

Gmelin's Method: Fuming nitric acid is placed at the 
bottom of a test tube and the urine allowed to flow gently down 
the sides of the test tube and form a layer above the acid. If 
the bile pigments are present there will be a green ring at the 
line of contact and below it in order, rings of violet, red and 
yellow will appear. 

Rosestbach's Test : The urine is filtered and the filter paper, 
which will be stained yellow, is touched with a drop of fuming 
nitric acid. If bile pigments be present, the rings will be formed 
as in Gmelin's test. 

Rosin's Test: On the surface of the urine in a test tube, 
dilute iodine solution is floated. If bile pigments be present, a 
grass-green zone will be formed at the line of junction of the 
two fluids. 

BILE ACIDS. 

Bile acids in small traces occur even in normal urine. They 
are increased in any condition in which there is a deficient 
elimination of bile, such as early cirrhosis, hepatic congestion, 
malarial poisoning, hepatic tumors, cancer and amyloid disease. 



21 

Oliver's Peptone Test: Peptone, grammes 30. 
Salicylic acid, grammes 4. 
Acetic acid, half ounce. 
Distilled water to make eight ounces. 

Dissolve all the ingredients and filter until perfectly clear. 
Prepare the urine by rendering it acid and diluting to a 
specific gravity of 1008 and filter until perfectly clear. 

To 3 cc of the test solution in a test tube, add 1 cc of the 
urine. If bile acids be present in excess, a distinct milkiness will 
at once appear. If 3 cc of the urine are required to produce the 
milkiness, bile acids are not present in excess. 



ACETONITEIA. 

Acetone occurs in the urine in a variety of conditions. It is 
stated by some authors to occur in very minute quantities even 
in normal urine, but only about 0.01 grammes per day. 

It occurs in many of the fevers and is then called febrile 
acetonuria. It is increased in most cases of diabetes in the later 
stages being often found in great excess. It occurs also in inani- 
tion, carcinoma and in psychoses. 

Tests: Small amounts of tincture of iodine and a solution of 
caustic potash are added to the urine and it is allowed to stand 
for a short time, when, if acetone is present in the proportion of 
one in 5000 crystals of iodoform will be precipitated and may be 
recognized by their form under the microscope. 

Chautard Test: Distill 200cc of the urine at a gentle heat 
and test the first 15cc of the distillate with sulpho-rosanalinic 
acid. If acetone is present, a fine reddish-violet coloration appears, 
the intensity of which varies with the amount. It is stated that 
less than 0.01 per cent, can be detected in this manner. 

Sulpho-rosanalinic acid, the reagent used in the above test, 
can be prepared by dissolving 0.25 gramme f uchsine in 500 cc of 
water, then passing a current of sulphur di-oxide through it until 
the yellow color disappears. As it is very sensitive to oxidising 
agents it must be kept in a well stoppered bottle. 



DIACETUKIA. 

Diaceturia never occurs in health and is shown by the presence 
of diacetic acid in the urine. It occurs (with a simultaneous 
abundance of acetone) in diabetes, especially when severe and 
about to go into coma,- and in febrile affections, especially in 
children. It is supposed to be the cause of the convulsions which 
occur so frequently in the course of febrile affections in children. 

Tests : Add some solution of ferric chloride, a precipitate may 
form of the phosphates and if so must be filtered off. More iron 
chloride must be added and if diacetic acid is present the urine 
becomes a Bordeaux-red. Then repeat with urine that has been 



22 

boiled. Then mix a portion of the urine with sulphuric acid, 
extract with ether, and repeat the chloride of iron test with the 
ethereal extract. 

Diacetic acid is present, if in the 'presence of the chloride of 
iron reaction the following reactions occur: 

1) The urine after boiling shows little or no reaction with 
the chloride of iron test. 

2) The ethereal extract shows a chloride of iron test fading 
in twenty-four hours or less. 

3) When acetone is also present. 



AMMONIA. 

Of almost equal value is the determination of the amount of 
ammonia in the urine. Ammonia seems to be formed by nature 
in an attempt to neutralize the acids which are formed in the 
system antecedent to the acetone and diacetic acid and which 
are supposed to be the cause of the coma and other nervous 
disturbances. 

Determination" : Take 10 cc of urine and place in a flask 
and exactly neutralized with a deci-normal caustic soda solution, 
using Rosolic solution as an indicator. 10 cc of a deci-normal 
sulphuric acid are then, added and boiled to expel carbon dioxide. 
Deci-normal caustic soda is then added until the red color is just 
restored. The number of cc of deci-normal sulphuric acid less 
the number of cc of caustic soda, the result multiplied by 0.0048 
gives the number of grammes of ammonium carbonate in 10 cc of 
the urine. 

In diabetes, if the patient is excreting more than 1.1 gramme 
per day he is suffering from a severe attack of the disease. If 
he is excreting more than this, two, four, six or more grammes of 
ammonia per day, he is in danger of passing into diabetic coma. 
Care must be taken in this test that the urine is fresh, if allowed 
to stand for some time the amount of ammonia is increased by 
the fermentation and decomposition of the urea. Care must also 
be taken that the urine is exactly neutralized before the sulphuric 
acid is added, as the normal acid reaction of the urine will neu- 
tralize some of the alkali if not exact. 



BLOOD AND BLOOD PIGMENTS. 

Tests: Heller's Test: A small portion of the urine in a 
test tube is made distinctly alkaline with caustic potash and boiled. 
The phosphates are precipitated and carry down with them the 
coloring matter of the blood, giving the precipitate a brown or 
reddish -yellow color. Should the urine be poor in phosphates the 
suspected urine should be mixed with an equal amount of urine 
containing a normal amount of phosphates and the test applied. 

Guaiac Test: For use equal parts of fresh tincture of 
guaiacum and old oil of turpentine are mixed in a test tube and 



23 

the urine floated carefully over it. At the line of junction, in 
addition to the deposit of resin, an indigo-blue ring will develop, 
and on shaking will give to the whole fluid a non-transparent 
blue color, fading in a few minutes. 

IIaemln" Test: A drop of the urine is evaporated on a glass 
slide, with a crystal of common salt. The deposit is then mois- 
tened with a drop of glacial acetic acid and boiled. When 
cool examine under the % lens, and if blood or haemoglobin be 
present the characteristic rhombic brownish crystals of haematin 
hydrochloride will be seen. 

Haematuria can be differentiated from haemoglobinuria by 
microscopical examination. In the former we find the above 
color reactions, and in addition the presence of a number of red 
corpuscles, while the latter shows the chemical reactions for 
blood, while microscopically few or no red corpuscles can be seen. 



DIAZO REACTION. 

It has been found that in most cases of typhoid fever, and 
in some other diseases such as measles and tuberculosis, the urine 
contains some undetermined compound which gives a peculiar 
reaction w T ith diazosulphobensol. 

To secure fresh diazosulphobenzol Ehrlich uses two solutions. 
No. 1 a ^ solution of sodium nitrite, and No. 2 containing two 
grammes of sulphanilic acid and 50 cc of hydrochloric acid in 
1000 cc of water. 

Test : Forty parts of No. 2 ; one part of number one ; forty- 
one parts of urine are thoroughly mixed in a large test tube. 
S-trong ammonia is floated on this mixture. 

If the diazo reaction is present, a carmine red ring will form 
at the junction of the two fluids, after shaking the foam will 
have a characteristic salmon-pink color, and after standing for 
twenty-four hours there will be a greenish precipitate. 

The urine must be perfectly fresh for success with this 
reagent. 

MICROSCOPIC EXAMINATION. 

By sediment in the urine we refer to any deposit from the 
urine which is visible to the naked eye, or can be detected by 
microscopic examination. 

The sediment is best obtained by means of the centrifuge, by 
the use of which we get the unchanged sediment of the urine, 
unaltered by standing and fermentative processes. As these 
instruments are expensive, most physicians will content them- 
selves w T ith a cheaper apparatus. Very satisfactory examinations 
may be made by allowing the urine to stand for about two hours 
in a conical glass, then withdrawing the sediment with a pipette, 
placing a single drop on a clean glass slide and covering with a 



24 

clean cover-slip. This may be examined with an objective mag- 
nifying about 400 diameters (about 1-5 or 1-6 objective.) 

. The sediments occurring in the urine may be divided into 
two classes, organic and inorganic. 



ORGANIC SEDIMENTS. 

Mucous, occurs (1) in small granules, visible to the naked eye, 
which, under the microscope prove to be aggregations of pus cor- 
puscles, held together by a small amount of transparent mucous. 

2) In the form of microscopic threads one to two centimetres 
in length, which under the microscope may consist of a closely 
packed thread of pus corpuscles held together by mucous, or may 
consist almost entirely of mucous with a few pus corpuscles 
attached to them. These are the so-called "mucous threads" of 
gonorrhoea, and are often found to contain the gonococci in cases 
of chronic gonorrhoea in which the discharge may have ceased 
entirely. 

3) Mucous also occurs in the form of microscopic threads, 
"cylindroids" which resemble very much some forms of renal 
casts. Usually they may be easily distinguished from casts by 
their irregular outline, being thin in one place, quite thick in 
another, by the appearance of mucouslike striation, and by their 
considerable length. 

Red Blood Corpuscles : Red blood corpuscles in the urine 
may be due to hemorrhage anywhere in the urinary tract. When 
from the urethra the blood is passed with the first portion of the 
urine, is often bright red and frequently is coagulated in a kind 
of cast of the urethra. 

Haematuria, the blood coming from the bladder, is charac- 
terized by the variable amount of blood, and by the fact that 
the blood is not intimately mixed with the urine, often being 
present in distinct clots. 

Vesical haemorrhage may be due to severe cystitis, tumors, 
especially in villous growths, stone and in a few rare cases due 
to the presence of various parasites, such as a variety of cercomonas. 

Haemorrhage from the pelvis of the kidneys resembles the 
haemorrhage from the bladder, and may be accompanied by the 
passage of coagula molded to the form of the ureter. The most 
common causes of haemorrhage from the pelvis of the kidney are 
the presence of stones in the pelvis and tumors. 

True renal haemorrhage occurs in acute and chronic haemorr- 
hagic nephritis, in infarction, marked renal congestion (usually due 
to irritating drugs) in tumors and injuries of the kidneys. It occurs 
also without kidney lesions in malaria, scorbutus and in the hae- 
morrhagic diathesis. In true renal haemorrhage the blood is 
intimately mixed with the urine, giving the urine a smoky or 
brownish hue. The corpuscles under the microscope may retain 
their normal shape and color, or they may have lost their color 
and appear as clear colorless rings. The corpuscles may be 



25 

formed into the blood-casts (see below) and are then characteristic 
of renal haemorrhage. 

Pus Cells: Pus cells occur in the urine whenever there is 
suppuration going on in any part of the urinary tract, and in 
smaller numbers, in acute and chronic nephritis. They may be 
due also to the rupture of a collection of pus from outside into 
the tract. They appear as small round granular bodies, with one 
or more nuclei, which may be rendered more distinct by the 
addition of a little acetic acid, or by treatment with staining 
agents snch as methylene blue. A few pus cells may occur in the 
urine in a normal individual, and it is only when present in 
quantity that they become pathological. 

Epithelial Cells: Epithelial cells may be derived from any 
part of the urinary tract and occur in any inflammation of the 
mucous membrane lining this tract. They vary much in size and 
shape, and no definite conclusion can be drawn from the size and 
shape with regard to their source. In general, those from the 
bladder are large, thin, flat, polygonal cells with a small clear 
nucleus. Those from the deeper layers of the bladder have the 
appearance of columnar cells, or caudate, smaller in size with a 
larger nucleus. Epithelium from the renal tubules are small, not 
much larger than a len oocyte, are irregular in outline but usually 
rounded, and contain a large distinct nucleus. It is impossible 
to say that any single cell is from a definite place in the urinary 
tract, but when numerous cells are seen, having the general 
characteristics of one of the classes as given above, a fairly accu- 
rate opinion can be arrived at by a careful observer. In women, 
care must be taken to prevent contamination of the urine by any 
vaginal discharge. This is best avoided by drawing the specimen 
with a catheter, or in cases where this is impossible, by giving 
the patient a vaginal douche before the specimen is passed. 

Tumor Cells: Bits of tumors are sometimes passed in the 
urine, but rarely in such a form that they are available for 
diagnosis. In the cases in which bits of tumors are passed they 
should be hardened as any tissue for microscopic examination, 
and after hardening, cut with the microtome. The diagnosis of 
these tumors belongs to the pathologist. 

Spermatozoa : After every discharge of semen these are to be 
found in the urine and are easily recognized. They are found after 
epileptic attacks and occasionally in severe diseases of all kinds. 

Casts : These are the most important of the formed elements in 
urine, and always occur with albuminuria. They vary much in 
size, form and. composition in the different varieties of renal disease. 

The following varieties may be described : 

Hyaline Casts : These vary much in size, sometimes nar- 
rower than the diameter of a white corpuscle, again four or five 
times as wide, and their length may be as great as one millimetre. 

They are colorless and transparent, and may be easily over- 
looked by a careless observer. Their ends may be rounded or they 
may look as though broken off. In many cases various urinary 



26 

deposits and other bodies, such as red and white corpuscles, may adhere 
to them and render them difficult of recognition. These hyaline casts, 
with granular material adherent to them, are called granular casts. 

Blood Casts: These are collections of red blood corpuscles, 
held together by coagulation. These only occur in renal haematuria. 

Epithelial Oasts are either hyaline casts, with epithelial 
cells adherent to them, or they are true casts of the tubules, a 
portion of the epithelial lining of the tubule having been exfoliated 
and washed down in the urine without disintegrating. They are 
most frequently found in acute nephritis, but may occur in any 
form, least frequently in the small granular kidney (chronic 
interstitial nephritis). 

Parasites: Animal parasites in this country are infrequent, 
usually when found in the urine being due to contamination from 
the vagina. Oxyuris vermicularis and trichomonas vaginalis occur 
in this way. In rare cases, a species of Cercomonas, resembling 
that found in the vagina and the one occurring in the intestine, 
is found in the urine, and in these cases there is usually a severe 
form of cystitis, with occasional haematuria, the urine retaining 
its normal acidity, or the acidity may be increased. 

Vegetable Parasites : Many different forms of bacteria may 
be found in the urine under diseased conditions. In the healthy in- 
dividual the urine as drawn from the bladder will be found aseptic. 

After standing even a short time the micrococcus ureae develops 
and is the factor which transforms the urea into ammonium car- 
bonate and gives the urine an alkaline reaction after standing; 

In cystitis we find a number of bacteria, the commoner ones 
being colon bacillus, streptococcus and staphylococcus pyogenes 
aureus and the gonococcus. In a few cases the typhoid bacillus 
may be the cause of cystitis. The tubercle bacillus is not infre- 
quently found as the cause of a chronic ulcerative cystitis and 
should be sought for in the sediment. The culture and differen- 
tiation of these bacilli belongs to the bacteriologist. 

Many other bacteria may occur in the urine in disease, often 
passing down from the kidneys in infectious diseases. 

Yeast cells occur in diabetic urine, usually in abundance 
and multiply rapidly, they occur occasionally in urine not con- 
taining sugar, but in these cases do not increase. 

INOKGAMC SEDIMENTS. 

The character of the crystalline deposit in urine varies with 
the reaction of the urine. 

In acid urine the usual deposits are of potassium, calcium 
and sodium urate (amorphous), uric acid and calcium oxalate. 

From alkaline or neutral urine the deposits are usually the 
ammonio-magnesium phosphate (triple phosphate), phosphate and 
carbonate of lime, urate of ammonia, and rarely uric acid. 

Uric Acid: As stated before this may be present in acid, 
neutral or rarely in alkaline urine. It may often be detected by 
the naked eye as reddish grains clinging to the side of the reagent 
glass. Microscopically it presents numerous forms, "whetstone" 



27 

shape, barrel shape, and crosses and more frequently still amor- 
phous masses of a reddish-yellow color or in superimposed plates 
of the same color. Uric acid precipitated from the urine always 
has this color, due to the coloring matters of the urine carried 
down with it (probably in most cases uroerythrin), while chemi- 
cally pure uric acid is colorless. 

The separation of uric acid crystals does not indicate an 
excess of uric acid, as it may be thrown down in any urine after 
standing a short time. 

Urates of sodium, potassium and calcium occur as the reddish 
"brickdust" precipitate which separates on cooling. They are 
immediately dissolved on warming, and under the microscope are 
seen as fine granules. 

Oxalate of Calcium: A few crystals of this may separate 
from any urine after standing a short time. In some cases they 
are very abundant, making up nearly the whole of the sediment. 
Their presence does not indicate necessarily an excess of oxalic 
acid, which can only be proven by chemical tests. They are in 
excess after eating certain vegetables and fruits, apples, pears, 
cauliflower, rhubarb and various sorrels, and in diabetes mellitus, 
hypochondria and in some cases of chorea. 

Its most common form in the urine is the small nearly square 
envelope form, more rarely it occurs in hour-glass or dumb-bell 
forms. They are insoluble in acetic acid and colorless, and are 
thus distinguished from triple phosphates. 

Triple Phosphates : These are the commonest crystals seen 
in alkaline urine and present themselves in numerous shapes. 
They occur in the coffin lid or whetstone form, as envelopes 
nearly square, as feathery crystals, and as thin plates. Some of 
the forms resemble calcium oxalate crystals, but may be differ- 
entiated from them by their solubility in acetic acid. 

Ammonium Urate: Urate of ammonia is present in all urine 
which is alkaline from fermentation. It is precipitated in reddish 
crystals, some of them being simply round spherules, others as 
reddish spheres with sharp spines projecting from them, the 
so-called " hedge-hog" crystals. 

Phosphate of Calcium is found as thin colorless plates in 
simple alkaline urine, and is destroyed by fermentation. 

Carbonate of Calcium occurs as colorless granules, often 
associated in pairs. It is found in simple alkaline urine and in 
urine alkaline from fermentation. 

Cystic is a rare sediment, occurring in thin, colorless poly- 
gonal plates, and may be a constituent of urinary calculi. 

Lencin and Tyrosin: These rare substances usually occur 
together, and may be present in the sediment, or may appear only 
when the urine has been evaporated to a syrupy consistency. 
Lencin appears as faintly shining spheres, and if large may show 
concentric rings and radiating lines. Tyrosin occurs as fine 
needles, usually collected into bundles. 

They are found in acute yellow atrophy of the liver, in 
acute phosphorus poisoning, occasionally in typhoid fever, small- 
pox and pernicious anaemia. 



BLOOD. 



In examining the blood, the main points to be noticed are' 
the amount of haemoglobin, the number, form, size and variations 
in color of the red corpuscles ; the number, classes and proportions 
of each variety of the lencocytes, and the occurrence of parasites. 

Haemoglobin": The amount of haemoglobin may be esti- 
mated by the appearauce of the mucous membranes, by the 
appearance of a drop of the blood, or by some form of haemoglo- 
bin ometer. A deficiency in the amount of haemoglobin, if very 
marked, may be easily detected by the pallor of the mucous 
membranes, and by the pale, watery appearance of the blood when 
drawn. 

The most accurate clinical test is by the use of the haemo- 
globinometer. Several forms of this instrument are in the market, 
the best probably being the instrument devised by Fleischl. A 
certain small quantity of blood, obtained by pricking the end of 
the patient's finger or the lobe of the ear, is measured by filling 
a capillary tube. The blood is washed into a chamber with 
distilled water and the chamber exactly filled with the water. The 
other division of the chamber is filled with water, the chamber 
placed on the stand of the instrument, a long hollow cylinder 
painted black on the inside, is placed over it to exclude all light 
except that from the mirror below, and the color compared with 
that of a colored glass wedge which fits in the stage. This glass 
wedge is moved by means of a thumbscrew until the tints are 
exactly the same, when the percentage of haemoglobin may be 
read off from the graduated scale. Artificial light must be used 
in this determination, so the test must be conducted in a dark- 
ened room. The amount of haemoglobin in general corresponds 
closely to the number of red corpuscles, in only two blood diseases 
is there any great disparity. In chlorosis the number of red 
corpuscles may be normal or only slightly decreased, while the 
haemoglobin registers very low, falling as low as 30 per cent. 
On the other hand in pernicious anaemia the number of red cor- 
puscles falls very low, even to less than 1,000,000 to the mm 3 
and while - the percentage of haemoglobin falls very low it never 
falls as low in proportion as the red corpuscles. 

Bed Corpuscles: The red corpuscles are best counted by 
the Thoma-Zeiss apparatus. This consists of a pipette graduated 
accurately, and a glass plate, divided by means of fine lines into 
minute squares. This small glass plate is placed on a glass slide 
and surrounded by a glass plate, 1-10 millimetre thicker than the 
graduated plate. This leaves a well 1-10 of a millimetre in depth, 
the bottom of which is formed by the graduated plate. This is 
subdivided by double lines into sixteen large squares, and each of 
these is again sub-divided into sixteen smaller squares. These 



29 

smaller squares measure 1-20 of a millimetre on each side, thus 
giving a chamber over each square 1-20x1-20x1-10, having a 
capacity of 1-4000 mm 3 . 

The finger or lobe of the ear is cleaned thoroughly and 
sharply pricked with a clean needle. A drop of blood is allowed 
to exude, avoiding pressure if possible. Take the pipette and 
draw the blood up to the graduation 0.5 or 1.0 and then draw 
in the diluting fluid to 101. Shake well to thoroughly mix the 
blood, blow out the drop of salt solution in the capillary tube, 
then blow a small drop of the blood on the centre of the glass 
plate, cover with the cover-glass (avoiding bubbles of air) and 
after a short interval to allow the corpuscles to become quiet, 
examine under the 1-5 or 1-6 inch objective. 

Care must be taken that the drop of blood is not too large 
and that it does not flow off from the small glass circle upon the 
large outer plate. 

After focusing the microscope, commence counting on the 
upper left-hand square of the field, counting those that touch the 
upper and left-hand lines and all those that lie free in the square, 
but not those that touch the lower and right-hand lines bounding 
the square. This is to avoid counting any corpuscle twice. After 
counting the sixteen squares seen under the field, the slide is to 
be moved and another set of sixteen counted. Three different 
drops are to be counted in this way and the average of the six 
counts taken for the calculations to secure accuracy. 

The calculation is as follows : Divide the average obtained, by 
sixteen to find the average number in one of the smaller squares. 
If the blood was drawn up to the mark 0.5 multiply by 200, for 
in this case the blood was diluted 200 times; if to the mark 1.0 
then by 100 for the dilution was then 1:100 and finally multiply 
by 4000; for the small square, the unit of capacity was 1-4000 of 
a mm 3 . This gives you the number of red corpuscles in a mm 3 . 
In health this averages in the male 5,000,000, in the female 
4,500,000. As a diluting medium it is best to use a normal salt 
solution, six gramme of sodium chloride to 1000 cc of water. 

White Corpuscles : The same glass slip is used in counting 
the white corpuscles as was used for the red corpuscles. A 
special pipette giving a dilution of 1:10 or 1:20 is used for mixing 
the blood. The blood is diluted with a 0.3$ solution of acetic 
acid, or by a staining solution which I have found more satis- 
factory. This is made up by adding to the 0.3$ solution of acetic 
acid, enough methylene blue to make a bright blue. After 
standing a short time the nuclei of the white corpuscles will be 
stained a distinct blue, while the red corpuscles are completely 
decolorized by the acid. It is best in counting the leucocytes, to 
count all the corpuscles in the sixteen large squares, and repeat 
this on five successive drops, finally making the calculations from 
the average of these. The calculations are as for the red corpuscles, 
allowing for the different number of squares, and different dilution. 



30 

Diffekential Staining: In the normal blood five different 
kinds of colorless corpuscles can be distinguished. 

1) Small leucocyte or lymphocyte. 

2) Large leucocyte or lymphocyte. 

3) Transitional forms. 

4) Polynu clear, neutrophilic leucocyte. 

5) Eosinophils 

In some diseased conditions a sixth corpuscle makes its 
appearance, the myelocyte. 

To prepare specimens of blood for staining the cover-glasses 
are carefully cleaned in dilute nitric acid and alcohol and care- 
fully dried. The finger is cleaned thoroughly, dried, then rubbed 
vigorously to stimulate the circulation, a small puncture is then 
made with a clean needle, and the blood allowed to exude. 
One of the cover-glasses is placed on the drop, then placed on 
another glass to spread the drop thinly and evenly, and finally 
they are drawn apart, care being taken to draw them apart in 
the same plane. 

If the examination is for the demonstration of micro-organisms 
all the minutiae of disinfection must be gone through with. 

These thin specimens soon dry in the air, if properly made, 
so rapidly that the red corpuscles do not become crenated or 
misshapen. These specimens may be hardened in several ways. 
They may be heated to a temperature of 120 °c for an hour, or 
hardened in a mixture of equal parts of absolute alcohol and 
ether for an hour, or in bichloride 1:1000 or 2$ solution of for- 
maline for the same length. The alcohol and ether hardening 
has on the whole given me the best results, the heat method 
coming next in efficiency. 

After hardening in this manner they may be preserved indefi- 
nitely if preserved from dust and moisture. When ready for 
examination they may be stained with any of the analine stains 
or with haemotoxylon and eosin. If eosin is used, it must be an 
alcoholic solution of about 70$ alcohol. 

For routine work, it is better to use some stain made up on 
the plan of Ehrlich's triple stain. The one in use in the labora- 
tory is made up from the following formula: Make saturated 
aqueous solutions of acid fuchsine, methyl green crystallized and 
orange G-. extra. 

Take of the saturated solution of orange G. 55 cc, of the 
solution of acid fuchsine 50 cc and add to them 100 cc of dis- 
tilled water and 50 cc of absolute alcohol and shake. 

Take of the saturated solution of methyl-green 65 cc, add to 
it 50 cc of distilled water and 12 cc of absolute alcohol, shake 
well and add to the first mixture drop by drop, shaking between 
the addition of each drop. 

With this stain the nuclei of the leucocytes are stained green, 
the nuclei of the nucleated red corpuscles 'if any be present, an 
intense green nearly black, the neutrophilic granules a purple, the 
eosinophilic granules a bright red. 



31 

This stain must stand for about three weeks before it is fit 
for use, and then is used by simply patting a few drops on one 
of the covers prepared as above, allowing it to remain about four 
minutes, wash with water, dry quickly in filter paper, and mount 
in balsam. Examine under the 1-12 oil-immersion objective with 
the Abbe condenser. 

The small mononuclear leucocyte with this stain presents a 
single green nucleus, surrounded by a very narrow rim of pink 
protoplasm, not larger than the red corpuscles. 

The large mononuclear leucocyte presents a single greenish 
nucleus about the size of the preceding, round, surrounded by a 
comparatively wide margin of pink protoplasm, not granular. 
This cell is larger than the red corpuscle, its main distinguishing 
feature from the small leucocyte. 

The transitional leucocyte is about the same size and appear- 
ance as the large mononuclear leucocyte, the nucleus, however, 
showing irregularities and the protoplasm occasionally shows 
evidence of beginning granule formation. 

The polynuclear neutrophile presents from two to six distinctly 
stained green nuclei, a wide rim of protoplasm with a large 
number of small purplish granules. It is much larger than any 
of the preceding, being from 12 to 14 micro-millimetres in 
diameter on the average. 

The Eosinophile resembles the preceding, but its granules with 
the stain mentioned or with eosin and haemotoxylon are large, dis- 
tinct, red, and often overlap the nuclei. 

The myelocyte is stated to be diagnostic of lencocythaemia. It 
is a large mononuclear, neutrophile, the nucleus large, not staining 
very distinctly, the protoplasm presenting the small purple gran- 
ules, resembling those of the polynuclear neutrophile. 

The normal red corpuscle with this stain, is a bright bun* 
tint, in some cases of disease, showing much lighter than normal, 
this condition being found in many of- the acute infectious diseases. 

The nucleated red corpuscle appears a distinct buff color with 
a single nucleus, staining intensely and appearing almost black. 
This occurs normally in the blood of infants, and is found after 
severe haemorrhage in lencocythaemia, pernicious anaemia, and 
occasionally in any severe anaemia. 

The proportion of each of these forms of white corpuscles varies, 
but the normal blood will show from 60 to 70$ of polynuclear neu- 
trophils, from \ to 2$ of eosin ophiles, from 6 to "l2# of large 
mononuclear leucocytes, from 1 to 3f of transitional leucocytes, 
and from 15 to 25$ of the small mononuclears. The proportion 
of white to red corpuscles in health varies from 1:400 to 1:700. 
A temporary increase or an increase not exceeding 1:20 is usually 
called leucocytosis. Leucocythaemia, on the other hand, is char- 
acterized by an enormous increase in the white corpuscles, which 
may reach the proportion of three white to two red corpuscles, 
and by the presence of the large mononuclear neutrophile cells 



32 

mentioned above. Under treatment the proportion of lencocytes 
may become nearly normal, but the myelocytes are persistent and 
characteristic of the disease. 

Leucocytosis occurs in the acute infectious diseases, with the 
single exceptions of typhoid fever and acute miliary tuberculosis, 
it occurs with suppuration in any part of the body, it occurs in 
the second and third stages of tuberculosis when the disease has 
has gone on to cavity formation. A physiological leucocytosis 
also occurs after meals. The normal number of lencocytes varies 
from 4000 to 6000, and in these diseases may be increased to 
30,000 or 40,000. 

Not much can as yet be said of the diagnostic significance of 
variations in the proportions of the different varieties. 

The blood may be examined for parasites, either fresh or in 
the stained specimens. Parasites of the blood may be either 
animal or vegetable. In this country almost the only animal 
parasite is the plasmodium or Haemotozoon malariae. This is 
always found in malarial fever of any type, and is the only 
absolute diagnostic point. Many different forms of this parasite 
are known, but may be grouped into a few general classes. 

1) Colorless bodies embedded in red corpuscles, about one- 
fourth the size of the corpuscle, and possessing amoeboid movement. 

2) Bodies resembling the preceding form, but containing a 
considerable amount of small granular brownish pigment. 

3) Large clear bodies, larger than a red corpuscle, containing 
more or less of the brownish pigment granules, usually arranged 
about the periphery of the body. 

4) Small bodies about one-quarter the size of a red corpuscle, 
lying free between the cells, and possessing active movement. 
These are the so-called spores. 

5) Small round motile bodies larger than the preceding having 
one or more cilia; called flagellate organisms. 

6) Crescentic shaped bodies, with or without a small amount 
of pigment, embedded in the thickest portion of the crescent near 
the center. 

7) Bodies composed of small irregularly rounded particles 
grouped around a central mass of pigment. 

These parasites are best studied in -the fresh specimens with- 
out staining, using for the purpose the 1-12 inch oil-immersion 
objective. If thought necessary, the specimens may be prepared 
as described above, and stained with aqueous methyline-blue solu- 
tion or with other of the aniline dyes. 

The vegetable parasites include any of the pathogenic bacteria, 
and require special bacteriological technique for their detection, 
hence the main part of this subject must be given by the bacteri- 
ologist. In general, it may be said that the blood is drawn and 
the specimen prepared under strict aseptic precautions, the 
hardened specimens stained with the aniline dyes and examined 
under the 1-12 objective. 



EXAMINATION OF SPUTUM. 



By expectoration we mean any substance thrown out of the air 
passages by the act of coughing or hawking. Microscopically we 
can distinguish the following varieties of expectoration: 

1) Mucous sputum is either glassy and transparent or grayish 
white, usually quite tough. It occurs in acute bronchitis, and 
often has its source in the oro- or naso-pharynx. 

2) Muco-purulent sputum consists of a mixture of mucous 
and pus in varying proportions. Pus is recognized by its yellowish, 
green color and its opacity. 

3) Purulent sputum. Pure pus is not a common form of 
sputum. It occurs from the sudden rupture of an abcess or 
empyema and occasionally from the sudden emptying of a cavity. 
It is recognized by its color, opacity and lack of toughness and 
stickiness. 

4) Serous sputum is the diagnostic expectoration of oedema 
of the lungs. It is very fluid, but not so much so as serum, as 
it always contains more or less mucous. It may be light gray 
and transparent or may contain enough blood to give it the 
appearance of "meat- washings." 

5) Bloody sputum. Any of the preceding forms of sputum 
maybe tinged with blood or may contain small streaks of it. In 
pneumonia the characteristic sputum is a tough glassy mucous 
tinged with the coloring matters of the blood, which may render 
it bright-red, yellowish-red, rusty or even greenish. Sometimes 
blood may be the chief constituent of the sputum and in these 
cases constitutes haemoptysis. 

The odor of sputum is ordinarily stale, but in chronic bron- 
chitis with bronchiectases, in large cavities with decomposing 
secretion as in the last stages of phthisis and in gangrene of the 
lung the sputum may be very offensive. 

Foreign Substances: By the unaided eye certain foreign 
substances may be detected. In pneumonokoniosis the sputum 
may show the particles of coal dust quite distinctly. In inhala- 
tion of iron, dust the sputum may have a peculiar rusty color. 
Other foreign particles found in the sputum and due to inhala- 
tion may be seen in the sputum, such as the fine dust of flouring 
mills found in millers and the shining particles of sandstone 
seen in "stone cutters' phthisis." 

Fibrinous tubes or casts of the bronchial tubes are occa- 
sionally seen in acute and chronic fibrinous bronchitis. These 
casts are best seen by spreading the sputum in water on a glass 
plate with a dark background. 



34 

Small casts of the smallest bronchi are often found in asthma, 
less commonly in acute pneumonia, constituting the asthmatic 
"spirals." As these are very small it may be necessary to examine 
them under a low power of the microscope. 

Charcot — Leyden Crystals: These are slight, bluish shining, 
elongated octahedrals, varying much in size from those visible to 
the naked eye down to those only visible to a 1-6 objective. 
They occur quite abundantly just before and after asthmatic 
attacks. But are also found less constantly in acute and chronic 
bronchitis and tuberculosis. 

Microscopic Examination : Elastic threads are found in 
the sputum in gangrene and abscess of the lung, and also in 
tuberculosis. They present a double outline, and often present 
the alveolar structure of the lung. 

Tubercle Bacillus: By far the most important diagnostic 
constituent of the sputum is the tubercle bacillus. This occurs 
most abundantly in small white clumps or in thin white scales 
in the sputum, though they may be found in any portion of it. 
They are narrow rods, straight or occasionally moderately bent, 
their length varying from two to four micromillimetres. On 
account of its small size it is difficult to see without special 
staining. It takes up the aniline dyes with difficulty and when 
once stained is very resisting to the action of bleaching agents. 
Upon these characteristics a special method of staining is based. 

The specimen of sputum to be examined is placed on a glass 
cover-slip and spread thinly and evenly over its surface, taking if 
possible the small white clumps spoken of above for examination. 
After spreading it thinly and evenly it is passed three times 
through the flame of a Bun sen burner or a spirit lamp to fix it 
to the slide. One of the most convenient stains is the one 
devised by Gabbet. 

Two'solutions are used. The first one consists of one part 
of fuchsine in 100 parts of a 5$ solution of carbolic acid and 10 
parts of absolute alcohol. The second solution is made by dis- 
solving two parts of methylene blue in 100 parts of a 25$ solution 
of sulphuric acid. The glass slip prepared as above is boiled in 
the fuchsine solution for two minutes, then placed in the 
methylene-blue solution for one minute, rinsed in water, dried, 
mounted in balsam and examined under the 1-12 immersive lens. 
The tubercle bacilli in these preparations are stained a bright 
red, the rest of the cells and bacteria being stained a deep blue. 
Only two other bacteria stain in this way; the leprosy bacillus 
and the smegma bacillus. In staining secretions for tubercle 
bacilli, where there is any chance for contamination by these bac- 
teria, they may be differentiated by decolorizing for ten minutes 
in absolute alcohol after the carbol-luchsine stain. By decolorizing 
with absolute alcohol for ten minutes the stain is removed com- 
pletely from the smegma bacillus, while the stain of the tubercle 
bacillus is unaffected. The leprosy bacillus must be differentiated 
by cultivation experiments, but can usually be excluded by the 
clinical history of the case. 



35 

Pneumococcus : This coccus is the cause of croupous pneu- 
monia, is found also in many of the complications of pneumonia 
such as empyema and meningitis. It occurs in the buccal secre- 
tions of perfectly normal, healthy individuals occasionally. It is 
easily stained with any of the aniline dyes. It is a capsule 
coccus, one, two or three occuring in a capsule, which is elon- 
gated or oval. Sometimes it occurs in short chains. It may also 
grow without the capsule, the form usually seen in cultures not 
showing the capsule. 

Micro-cocci, bacteria and spirilla? of various kinds are often 
found in the sputum. They are much increased in fetid bron- 
chitis, in bronchiectases, in abcess and gangrene of the lung, 
They are most conveniently stained in aqueous methylene-blue. 
after preparation of a cover-slip preparation as above. 



qg^ 



EXAMINATION OF DISCHARGES. 



The discharges with which we are most concerned are purulent 
discharges from cavities, or from some of the natural outlets of 
the body. The common bacteria of suppuration, the staphylo- 
coccus and strep to-coccus are readily stained by any of the aniline 
dyes, one of the most distinct being aqueous solution of methylene 
blue. Their morphological and culture characteristics will be 
taught by the bacteriologist and are only referred to here. 

The gono-coccus is the only certain diagnostic point in 
gonorrhoea. A small drop of the pus is spread evenly on a cover 
glass, passed through a flame a few times and allowed to stand 
in aqueous methylene-blue solution for a few minutes. This is 
washed off and dried, finally mounting in balsam. The gono- 
coccus appears under the microscope as diplococci, shaped like a 
coffee bean, with the flat sides in opposition. 

The gono-cocci may be found free between the cells, in the 
epithelial cells, and in the pus cells. The position inside the pus 
cells alone is characteristic as the psuedo-gonococcus occurs free 
and in the epithelial cells, and can not be distinguished from it 
by size or form. In cases of chronic gonorrhoea it often happens 
that the discharge stops and the patient is apparently well. 
Careful examination of the urine in these cases often shows a 
large number of pus-cells, and a few structures resembling small 
bits of thread. If one of these "mucous threads" be examined 
under the microscope it will be seen to consist almost entirely of 
pus cells, held together by a small amount of clear glassy mucous. 
If stained with methylene-blue and carefully examined under the 
1-12 objective these will usually show a few gonococci. 



STOMACH EXAMINATION. 



In undertaking a chemical examination of the stomach contents, 
it is necessary to employ some standard meal or meals, whose rate 
of absorption, digestion and expulsion from the stomach into the 
intestine, has been carefully worked out by observation and exper- 
iment on normal individuals. 

We employ in our work two meals given in combination, the 
Salzer meal and the Ewald breakfast. The Boas oat-meal gruel 
which will be spoken of more in detail under the head of lactic 
acid is given in special cases. For routine work we use the Salzer 
meal and Ewald breakfast as follows : At 8 A. M. we give the 
Salzer meal, compound of one soft boiled egg, about 60 grammes 
of rice, 30 grammes of lean, cold roast beer, cut or hashed into 
small bits and about 250 cc of milk. Exactly four hours after this 
(12 M.) we give the Ewald breakfast composed of one roll without 
crust (35 to 70 grammes) and 300 — 400 cc of warm water. 

After one hour we withdraw the contents of the stomach by 
means of a small stomach tube, receiving the contents as they 
flow through the tube in a small clean basin, carefully avoiding 
any admixture of saliva with the contents. 

The first examination is macroscopic and much can be learned 
of the condition of the stomach from this. 

1. Appeakance : The stomach contents should be clear, 
almost colorless, and contain only particles of partially dissolved 
bread from the Ewald breakfast. Particles from the Salzer meal 
at once indicate either a disturbance of the secretory or motor 
function of the stomach. 

If a large amount of rice is found in addition to an excessive 
amount of the bread from the Ewald meal it usually indicates 
hyperacidity with faulty digestion of the starches. 

If on the other hand we find some amount of proteid 
material left from the Salzer meal such as particles of egg, meat 
or coagulated milk, we may at once conclude that there is sicbacidity 
or anacidity. 

Consistency : Normally the contents are quite fluid, flowing 
freely. They may be quite thick and ropy from the presence 
of an excessive amount of mucous. There may also be an 
excessive amount of mucous derived from the pharynx. This 
is easily recognized by the fact that the mucous is in clumps, and 
often, colored yellowish, greenish, and if in persons exposed to 
dust of a dark color. True stomach mucous is usually quite clear 
and spread uniformly through the contents. 

Smell : Normal gastric juice has a distinctly sour smell npt 
unpleasant. Under abnormal conditions the fatty acids may be 
formed by fermentative changes which give a very decidedly offensive 
odor to the contents. 



38 

Quantity: If possible to do so without injury to the patient, 
we may get the entire contents of the stomach which should not 
exceed 40 to 50 cc. If a very large amount * 200 cc or more of 
a milky chyme-like fluid we may suspect some motor disturbance 

Blood : Blood may be present as fresh unchanged blood or 
it may be black almost like coffee grounds due to the action of 
the stomach fluids upon it. If at all doubtful we may test any 
suspected particles by the Turpentine — Guaiac test or the Haemin 
test as given under urinary analysis. 

Bile : We can detect bile if present in large amounts by the 
color. If present in small amount only it may be recognized by 
any of the tests for bile pigment as given under urinary analyssis. 

Miceoscopical Examination: Allow the stomach contents 
to stand in a conical glass for a short time. We may then take for 
examination portions from each layer of the contents and examine 
either stained or unstained specimens. The examination has 
reference to portions of the mucosa or the deeper layers of the 
stomach, to possible presence of plain muscular fibers. In neoplasms 
of the stomach after ulceration has commenced we may (rarely) 
find bits of the tumor which if large enough to show the arrange- 
ment of the cells may lead to a diagnosis of the disease. Probably 
a very few leucocytes might be found even in a normal stomach, 
but if numerous are due to a gastritis. In rare cases of phleg- 
monous or diptheritic gastritis, or in rupture of an abscess from 
the surrounding organs into the stomach, pus may be present in 
sufficient quantity to be visible to the naked eye. 

Eed corpuscles may be found in haemmorrhage into the 
stomach unless it has remained too long in contact with the acids 
of the stomach. 

In cases of fermentation the frothy layer which rises to the 
top of the glass should be examined for bacteria. Under these 
circumstances we may find a number of kinds of bacteria, one of 
the commonest is called the sarcinae or wool-pack due to arrange- 
ments in fours. 

CHEMICAL EXAMINATION. 

After carefully filtering until the filtrate is clear we commence 
the chemical examination of the filtrate. 

Eeaction : Try first with blue litmus paper. If this is unchanged 
try again with red litmus which turns blue if the stomach contents 
are alkaline which occurs only in some cases of acute gastritis, in 
severe chronic gastritis and in cases where there has been a regur- 
gitation of alkaline bile and intestinal juice from the small 
intestine. If the blue paper is promptly reddened the reaction is 
acid and the next step is to ascertain the acid or acids to which 
the acidity is due. We first dip a strip of congo paper into 
the filtrate. This paper is prepared by soaking filter paper 
for an hour in a 1$ aqueous solution of congo-red and al- 
lowing it to dry. In the presence of free acids this paper 
turns blue but does not react to acid salts. If hydrochloric 



39 

acid is present the paper turns a dark blue not fading on the 
application of heat. Lactic acid turns the paper a dirty brownish 
blue which fades almost entirely when the paper is dried. 

Tests for free HCl : The simplest and most convenient test 
for the presence of free HCl is the indicator called Dimethvl-ami- 
do-azo-benzol. A \<f> alcoholic solution is prepared and kept in 
stock. A test paper is prepared by soaking filter paper in this 
for an hour and then drying. 

This indicator or paper turns red or pink when it is dropped 
or dipped into stomach contents containing free HCl. 

Boas' Test: Prepare a solution of resorcin resublimated five 
grammes, white sugar three grammes and 94^ alcoholic 100 cc. 
Mix three drops of this reagent and six drops of the filtered 
gastric juice on a round white butter dish and heat gently over 
a water bath or open flame. In the presence of free HCl a 
bright red ring or mirror will form as evaporation goes on, 
fading in a few minutes. If HCl is absent only a faint yellow 
stain will result, and if heated too rapidly the residue will char, 
giving a black residue. 

Guxzbekg-'s Test: This solution is prepared by dissolving 
2 grammes of phloroglucin and one gramme of vanillin in 30 cc of 
absolute alcohol. A yellow liquid results which gradually turns 
red and finally brown on an exposure to the light. This solution 
must then be \ kept in a dark bottle away from the light. This 
solution is used in exactly the same way as the Boas test given 
above. 

Lactic Acid: Lactic acid is present in traces in most of 
the test meals. It is formed by the action of certain bacteria of 
the mouth upon carbohydrates and is found in even healthy 
stomachs for some time after the ingestion of the meal, the curve 
of lactic acid acidity falling as the curve of HCl acidity rises 
until at the height of digestion no lactic acid should be demon- 
strable by ordinary tests. This fall in the amount of lactic acid 
is due to two factors; firstly the absorption of the preformed lactic 
acid secondly the antiseptic action of the HCl of the gastric juice 
inhibiting or destroying the bacillus which causes the acid fer- 
mentation. Many complicated tests have been devised for the 
detection of lactic acid but the most convenient one for clinical 
purposes is that of Uffelman. 

Test: A solution containing three drops of a strong solution 
of Ferric chloride and 3 drops of carbolic acid in 20 cc of water. 

This solution is a bright amethyst blue and should be trans- 
lucent when placed in a test tube!! To this solution add a few 
drops of the stomach filtrate which in the presence of lactic acid 
will give a bright canary yellow color. In some cases it is con- 
venient to make a layer test by placing a small amount of the 
filtrate in the bottom of a test tube and floating the solution upon 
it. Hydrochloric acid decolorizes the solution and butric acid 
gives a faint greenish-yellow color to the solution. 



40 

The persistent and excessive formation of lactic acid is stated 
to be quite characteristic of cancer of the stomach. In suspected 
cases therefore it is necessary to give some test meal which con- 
tains no lactic acid. Such a test meal is furnished by the Boas 
test meal. 

This consists of a tablespoonful of rolled oats boiled in a 
1000 cc of water until it measures 500 cc. This may be salted a 
little but nothing else added. 

The stomach is washed out thoroughly the night before the 
exhibition of this meal, the oatmeal gruel given in the morning 
and withdrawn again in one hour. The presence of an amount 
of lactic acid which can be demonstrated by the Uffelman test in 
conjunction with other symptoms renders the diagnosis of gastric 
cancer probable. 

Btjtykic Acid : Can usually be detected by its odor, that of 
rancid butter. 

Acetic Acid : This acid can usually be detected by its odor 
also. It may be demonstrated in the following manner. 

Tencc of the filtrate is extracted with ether, the ethereal 
extract evaporated after separation, the residue dissolved in a few 
drops of water and exactly neutralized with a dilute solution of 
caustic soda. If a drop of a very weak solution of perchloride of 
iron be added to this a deep red color results in the presence of 
acitic acid. 

Deteemikatiof of Amount of Fkee HCl: The determination 
of the amount of free HCl is most conveniently done by the use of 
the indicator spoken of under tests for free HCl, viz: Dimethyl- 
amido-azo-benzol. Five or 10 cc of the filtered gastric juice is 
diluted with distilled water, a few drops (2 or 3) of the indicator 
added. In the presence of free HCl a red color develops. Care- 
fully add a decinormal solution of caustic soda until the red 
color disappears and the solution becomes a clear lemon yellow 
which indicates that all the free HCl has been neuralized. The 
degree of acidity is found as follows: 10 cc of the filtrate re- 
quired 1.5 of the decinormal solution of caustic soda to neutralize 
it and 100 cc would require 10 times 1.5 to neutralize it giving 
therefore 15 degrees of acidity due to free HCl. The percentage 
of HCl is found in a similar manner. Eachcc of the soda solu- 
tion will neutralize 0.00365 grammes of HCl, therefore the 10 cc 
contained 0.00365 x 1.5=0.005475 grammes of free HCl each cc 
contained 0.0005475 grammes the percentage being 0.05475. 

Method of Mintz : 10 cc of the stomach contents are treated 
with a decinormal caustic soda solution until they give no reaction 
with the Boas or Gunzberg reagents. Allowing for the loss due 
to a portion of the gastric juice being taken out for the Boas or 
Gunzberg test this gives a very reliable test for the HCl. The 
degrees of acidity and the percentage of HCl are found as in the 
previous method. 

Still quicker and easier is a method suggested to me by Dr. 
Hemmeter. A gastric juice containing only a small amount or 



41 

none of the fatty acids and lactic acid, is titrated with decinorrnal 
caustic soda solution until a small drop taken out with a platinum 
wire and dropped on a slip of cougo-paper does not change the 
color of the paper. In the presence of large amounts of lactic 
acid a dirty brownish blue discoloration of the paper will take 
place, even after the free HOI has been neutralized, so that great 
care must be exercised in these cases. 

Estimation of the Eatty Acids: Take the total acidity 
of a given quantity of the gastric juice. Another portion of the 
same amount exactly is evaporated on a water bath to a syrupy 
consistency and made up to the same volume again with distilled 
water. The evaporation has driven off the fatty acids and by 
taking the total acidity of this solution we may get the acidity 
due to the fatty acids by finding the difference between the first 
titration and the second determination. 

The acidity due to organic acids may be determined in still 
another manner. 10 cc of the filtered gastric juice is exactly 
neutralized with decinormal caustic soda solution. This is then 
evaporated to dryness and the residue burned, being careful not 
to carry the incineration further than the point at which the 
residue burns with a luminous flame. If carried beyond this 
point some of the chlorides are liable to be volatilized and lost. 
Dissolve the residue in 10 cc of water and titrate with decinormal 
sulphuric acid. 

By incineration all the organic acids were converted into car- 
bonates of the alkali used. These are titrated with decinormal 
sulphuric acid, and the amount of acid used will represent the 
amount of organic acids, which may be most conveniently 
expressed in terms of HC1. 

Estimation of Free HCl, Combined HCl, and Acid 
Salts, Organic Acids, Etc. The most convenient method of 
estimating the various forms of acid to which the total acidity 
of the stomach is due is that of Topfer. In this method three 
different indicators are used. 

1) 0.5 % alcoholic solution of dimethyl-amido-azo-benzol. 

2) 1% aqueous solution of alizarine. 

3) 1% alcoholic solution of phenol phthalein. 

In practice 5 or 10 cc of gastric juice is measured out into 
three beakers. A few drops of phenol phthalein and a few cc of 
distilled water are added to this and the mixture titrated with a 
deci-normal caustic soda solution until the rose color that appears 
when the neutral point has been nearly reached has deepened 
into a dark red. This color indicates that all the various acidities 
of the gastric juice have been saturated, viz.: the free HOI, the 
combined HCl, the acid salts and the organic acids. 

To the second beaker three or four drops of the aqueous 
solntion of alizarine are added and the solntion titrated with the 
caustic soda solution nntil a purple color appears. The appearance 
of this purple tint indicates that the free HOI, the acid salts and 
organic acids have been saturated, but not the combined HOI. 



42 

The difference between No. 1 and No. 2 therefore will be the 
amount of HOI in combination with albuminous matters of the 
food, the so-called "combined HC1," which has been secreted by 
the stomach and already performed its physiological functions in 
digestion. 

To the third beaker three or four drops of dimethyl-amido- 
azo-benzol solution are added. In the presence of free HOI, a 
decided red tint develops, but if absent only a yellow color will 
be found. If a red color, denoting the presence of free HC1 
appears, titrate with the caustic soda solution until the red color 
changes to a bright lemon yellow. The amount of NaOH needed 
to produce this change in color is the amount necessary to neu- 
tralize the free HOI of the gastric filtrate. The difference between 
the amount required to produce the purple color with alizarine 
and the amount necessary to produce the yellow color with the 
dimethyl-amido-azo-benzol will represent the amount of NaoH 
required to neutralize the acid salts and the organic acids of 
the filtrate. 

In stating the results of these determinations we may employ 
two methods. First, by stating the amount of NaOH in cc to 
neutralize each acidity in 100 cc of the filtrate as so many 
"degrees" of acidity. Second, by calculating each acidity into its 
equivalent in HC1 for one cc, remembering that each cc of deci- 
normal caustic soda solution will neutralize 0.00365 grammes 
of HOI. 

Winter's Method: This method is much longer and more 
complicated than the preceding method, but is interesting as a 
comparative method. Five cc of the filtered gastric juice are 
placed in each of three porcelain capsules and numbered one, 
two and three. 

No. 1 is evaporated to dryness and the residue burned until 
the residue ceases to burn with a luminous flame. By this treat- 
ment the free HOI and the combined HOI are driven off, leaving 
only the CI in combination with the inorganic bases. After cooling, 
the contents of the capsule are treated with a few drops of nitric 
acid and about five cc of distilled water, carefully stirred with a 
glass rod, neutralized by adding an excess of calcium carbonate, 
and filtered through a dry filter, which is carefully washed with 
distilled water until free from chlorine. 

No. 2 is evaporated down just to dryness, being careful to 
avoid burning, made up to 5 cc again with distilled water, an 
excess of pure sodium carbonate added and finally evaporated, 
incinerated the further treatment being the same as No. 1. 

No. 3 is treated immediately with an excess of sodium car- 
bonate, evaporated, incinerated and treated exactly as No. 1. 

By a study of the methods used it will be seen that No. 1 
contains the chlorine which was contained in the filtrate in com- 
bination with the inorganic bases. No. 2 contains the chlorine in 
the inorganic bases and the 01 in combination with the proteid 
bodies, the combined HOI, while No. 3 will contain the total 
chlorine, consisting of inorganic chlorides, combined and free HOI. 



43 

The amount of chlorine in each filtrate is then estimated as in 
the estimation of chlorides in the urine. 

The filtrate and the washings of the filter are placed in a 
flask, and to it is added about 4 cc of pure nitric acid of 1.200 
Sp. Gr. Add also 5cc of a saturated solution of ferric ammo- 
nium alum- and 15 cc of the standard silver solution. Titrate the 
mixture with the ammonium sulpho cyanate solution until a red 
color appears, due to the formation of the sulphocyanate of iron. 

Calculation: As in the absence of chlorides 37.5 cc of the 
ammonium sulphocyanate solution would be required to neutralize 
the 15 cc of silver solution, the difference between 37.5 cc and the 
number of cc actually required, represents the amount of silver 
nitrate used up in the saturation of the chlorides. 

Then as each cc of the ammonium sulphocyanate solution 
represents .004 grammes of JSTa 01, the amount of chlorine, esti- 
mated as Na CI, in the 5 cc of filtrate is found by multiplying 
the difference between 37.5 and the actual amount used by .004. 
The amount of chlorine may be found by the following formula, 
x being the number of grammes of CI estimated as Ka CI : 

58.4: 35.4:: x:( ). 

TOTAL ACIDITY. 

For many cases the determination of the total acidity is suffi- 
cient for diagnostic purposes. A small amount of the gastric 
juice 2.5 or 10 cc is diluted with a small amount of distilled 
water, and a few drops of a 1# alcoholic solution of phenol- 
phthalein added to it. Titrate carefully with a deci-normal caustic 
soda solution until a dark red color appears, denoting a faint 
degree of alkalinity of the mixture. The total acidity is expressed 
as so many "degrees" of acidity. 

For example, 5 cc of the filtrate required 2 cc of the caustic 
soda solution to neutralize it. Then if 100 cc of the filtrate had 
been taken 40 cc of the caustic soda solution would have been 
required to neutralize it, or it is more simply stated as 40 degrees 
of total acidity. In general terms it may be stated that after the 
double test meal of Salzer the normal stomach shows an acidity 
of from 40 to 60 degrees. The total acidity is increased usually 
in ulcer, in early stages of cancer developing on the base of an old 
ulcer, and in neuroses to which the general term hyperacidity has 
been applied. 

The degree of acidity is decreased as a rule in acute and 
chronic inflammatory diseases of the stomach, in carcinoma, and in 
many of the neuroses. A neutral or alkaline reaction is rare, 
most frequently occurring in chronic mucous gastritis, in pro- 
longed vomiting where some of the intestinal contents are forced 
into the stomach and ejected by vomiting, and in some cases of 
"morning vomiting" in which the vomited matter consists mainly 
of saliva which has been swallowed during the period of nausea 
preceding the act of vomiting. 



44 

Erythrodextrin: Ptyalin, the digestive ferment of the 
saliva, acts exclusively upon the starches, acting readily upon boiled 
starch, acting only slightly on raw starch. The end product of 
its action is maltose, a number of dextrin s being formed as inter- 
mediate products. This action only takes place in an alkaline or 
very faintly acid medium, even a moderate degree of acidity check- 
ing its activity. The first dextrin formed is erythrodextrin 
which gives a purple color with a dilute solution of iodine or a 
weak Lugol's solution. Achrodextrin the next product is nearly 
colorless, giving only a faint reddish tinge with Lugol's solution, 
while maltose, the final product is colorless. 

In the normal stomach, this action of the ptyalin continues 
for some little time, probably 15 or 20 minutes before the 
acidity of the gastric juice is raised to a degree sufficient to check 
the action of the ptyalin, and in this time the starch is mainly 
transformed into maltose and achroodextrin. 

On the other hand in cases of hypersecretion and hyperacidity 
the gastric juice reaches a degree of acidity sufficient to stop the 
action of the ptyalin before the starch is all transformed, and as 
a result we get the purple reaction of erythrodextrin. This test 
is of value as confirmatory evidence of hyperacidity. 

Examination" for Pepsin : Unfortunately we have no exact 
quantitative tests for pepsin so all tests must be relative. Pepsin 
is probably not secreted as such by the peptic glands but in its 
stead an enzyme or mother substance is secreted which is changed 
into pepsin by the acids of the stomach. This mother substance 
is called pepsinogen. The change from pepsinogen to pepsin is 
best performed by hydrochloric acid, but in the absence of hydro- 
chloric acid the same change is affected by the organic acids but 
less perfectly. 

Pepsin is best tested for by its action on egg-white. A small 
bit of egg-white .5 cm square by about 1 mm in thickness is 
placed in a test tube with 3 cc of the gastric juice and kept at 
a temperature of from 98° to 100° F for two hours. If Pepsin 
is present in normal amount the egg should be dissolved within 
this time. 

Pepsinogen: In case the gastric juice is alkaline, neutral 
or show no trace of free HC1 only organic acids being present, it 
is necessary to test for pepsinogen. Prepare three test tubes, 
placing in each 3 cc of the gastric juice and the small bit of egg- 
white as above. The first one is put in the warm oven without 
any addition to it. To the second 0.5 cc of a 1$ solution of hy- 
drochloric acid is added, and to the third 0.5 cc of a lf solution 
of hydrochloric acid, and a grain or two of pure pepsin and placed 
in the warm oven at a temperature of 98° to 100° and kept 
there for two hours. 

At the end of this time if all three show digestion of the 
egg, pepsin is present. If only No. 2 and No. 3 show digestion of 
the egg pepsin is absent ana* pepsinogen present, if only No. 3 
shows digestion of the egg, pepsin and pepsinogen are both absent. 

If digestion takes place in the tubes to which pepsin has 



45 

not been added, but requires longer than two hours, pepsin or pep- 
sinogen as the case may be is present but in diminished amount, 
indicating a decrease in the digestive powers. 

Rennet Ferment : Place 3 cc of good milk with a nearly 
neutral reaction in a test tube and add to it 3 drops of the gastric 
juice. Place it in the warm oven at the body temperature, where 
coagulation will take place in from 5 to 15 minutes should rennet 
ferment be present in normal amount. 

Rennet Zymogen: In the absence of free HOI, rennet 
zymogen may be present in normal amount while rennet ferment 
would be absent by the above test. It is tested for by exactly 
neutralizing about 3 cc of the gastric juice and adding a few drops 
in excess of caustic soda solution. Add to this 1 cc of a 1$ solu- 
tion of calcium chloride and 4 cc of neutral milk and place in the 
warm bath or oven for a few minutes. Coagulation should take 
place in from 5 to 15 minutes. 

Of considerable diagnostic and prognostic value is the quan- 
titative estimation of rennet zymogen. The secretion of HOI may 
be disturbed by many causes, motor and nervous, while rennet 
zymogen seems to suffer the least from these disturbances. Pre- 
pare several dilutions of the gastric juice 1:10, 1:20, 1:30, 1:50, 
1 : 75, 1 : 100 and 1 :150. Take 3 cc of each of these dilutions, faintly 
alkalinize them with caustic soda solution, and put in separate 
marked test tubes. Add to each tube 1 cc of a 1$ calcium chlo- 
ride solution and 4 cc of milk and place in the warm oven for 15 
minutes. At the end of this time notice the dilution at which 
coagulation has taken place. In the normal stomach, a dilution 
of from 1:100 to 1:150 should be active. In cases of gastritis the 
nitrate is active only in dilutions of 1 : 20 to 1 : 40. A gastric juice 
which is active only in dilutions below 1 : 20 is probably due to an 
atrophic gastritis, the prognosis with regard to a cure being very 
bad. From 1 : 20 to 1 : 40 the prognosis is fairly good. 

Test for Absorption: A gelatine capsule containing 0.2 
grammes of potassium iodide is given to the patient, shortly before 
a meal and the saliva examined for the presence of iodine at in- 
tervals of from 2 to 3 minutes. The most convenient method of 
conducting this examination is by means of starch paper and 
fumiug nitric acid. The starch paper is prepared by soaking un- 
glazed paper in boiled starch and allowing it to dry. When wanted 
for use moisten with a little water. The paper is touched with 
a rod dipped in the saliva or a small drop of the saliva dropped 
upon it. With a glass rod put a small drop of fuming nitric acid 
on this. A purple color is produced when the iodine makes its 
appearance in the saliva, .which takes place in a normal case in 
from 6 to 11 minutes. 

Motility: The best practical test for motility is the exam- 
ination of the contents of the stomach after the double test meal 
of Salzer. In the normal stomach there should be no trace of the 
Salzer meal itself. Simply a small amount of half -dissolved bread 
in a clear or faintly cloudy liquid. If there is meat, etc., there 



46 

probably is a deficient motor power of the stomach. In some cases 
where dilatation and atony is suspected it is advisable to withdraw 
the contents of the stomach in the morning before eating. In 
cases of dilatation and atony of a severe grade it is usual to find 
traces of the previous meal, taken the previous night, at least 12 
hours before the examination. 

Ewald's Test : One gramme of salol in a capsule is given the 
the patient immediately after the breakfast or dinner and the pa- 
tient directed to pass his urine at intervals of half an hour for 
two hours and save each portion separately. To a small portion 
of each a drop of a weak solution of ferric chloride is added which 
in the presence of salicyluric acid will give a purple tint. 

This test is based upon the fact that salol is broken up in 
an alkaline medium into carbolic and salicylic acid. Except in 
the presence of a large amount of alkaline mucous, this decom- 
position does not take place in the stomach, but on the other hand 
may not take place in the intestine, due to acid fermentation in 
the intestinal contents. 

Under normal circumstances the reaction may be demonstrated 
in the urine in from 45 to 75 minutes, being delayed in cases of 
atony to 2 hours or longer. A continued presence of the reaction 
up to 24 hours or longer is also indicative of obstruction or atony. 
It must be remembered also that in some cases of acute gas- 
tritis, all these tests may indicate serious disease, but that after a 
few days, recovery may take place and the stomach be found per- 
fectly normal. It is necessary therefore to make at least three 
examinations before a definite diagnosis and prognosis can be made. 

Examination of the Fasting Stomach: In health the 
stomach secretes continuously a small amount of juice containing 
usually a small amount of HOI, pepsin and rennet ferment. A 
variable amount may be obtained by expression, usually only a few 
cc. As much as 50 cc may be obtained in some cases from an 
apparently normal stomach. A secretion of over 50 cc points to a 
condition called peptonorrhoea, and may be combined with hyper- 
acidity, a condition known as continuous hypersecretion and hy- 
peracidity. 



c§<& 



EXAMINATION OF FAECES. 



Quantity of Faeces: Assuming that the gastrointestinal 
tract is unobstructed, the amount of faeces depends on the quan- 
tity and quality of food taken. It is easily seen that an increase 
in the amount of matter ingested and the ingestion of a large 
proportion of vegetable matter will lead to an increase as this 
latter contains a larger proportion of indigestible matter which 
cannot be absorbed. The quantity of faeces is increased in diar- 
rhoea, due either to a quickened peristalsis or to an effusion from 
the intestinal mucosa. After constipation, there may be a large 
amount of firm hard faecal matter, this increased excretion per- 
sisting for some days. In faulty absorption due to disease of 
the liver, pancreas, mesenteric glands or intestinal mucosa the 
amount of faecal matter is increased. 

Consistency and Form of Stool: The normal stool is firm 
or mushy. In diarrhoea the stool is thin, watery or like thin 
soup, due both to the increased peristalsis, or to insufficient 
absorption and in some cases to the exudation of fluid from the 
intestinal mucosa as in Asiatic cholera, severe cases of acute 
enteritis, dysentery and typhoid fever. The form of firm faeces 
has litttle diagnostic value, though a flat ribbon-like stool may 
indicate stenosis of the rectum and is seen in severe cases of 
prostatic hypertrophy. 

Odor : The variations in odor from the normal often have diag- 
nostic value. An odor of butyric acid with a slight acid reaction is 
seen in some cases of infantile diarrhoea with acid fermentation. A 
decidedly foul smell as of some decomposing animal substance is 
seen in more severe cases of this affection. When there is a con- 
siderable mixture with blood the faecal odor may be masked 
completely by the slightly unpleasant odor of blood. The stools 
of gangrenous dysentery, carcinomatous or syphilitic ulceration of 
the rectum often have foul cadaverous odor. 

Eeaction : Normally the reaction is nearly neutral, in nursing 
children faintly acid. 

It may be distinctly acid in acid fermentation, or distinctly 
alkaline in alkaline fermentation, in either case being due to a 
catarrhal condition of the intestinal tract. 

Color: The normal color is brown, varying in tint. This 
color is due to decomposition products of the biliary coloring 
matters. The stool may be colored by articles of food or by drugs. 
Iron colors the stool nearly black, bismuth a greyish-black. In 
obstructive jaundice the stool is usually mushy, greyish-white in 
color, often faintly glistening due to the presence of fat. Bilious 
stools on the other hand are those in which, due to rapid peris- 



48 

talsis, the bile pigments have not had time to undergo complete 
transformation. This may be demonstrated by filtering the faeces 
and testing the "filtrate for bile pigments as given under urinary- 
analysis. 

Foreign Particles : In the normal stool portions of food 
can be recognized with the unaided eye if indigestible particles 
have been eaten, such as the seeds and skins of various fruits. 
Large fibres of connective tissue, undigested portions of grains, 
etc., may be met with in the stools if the food has been eaten 
rapidly or in large quantities. Muscular tissue, clumps of casein 
and bits of starch may be seen in the stool in cases of catarrh of 
the stomach or small intestine or in the catarrh and rapid peris- 
talsis of some kinds of fever. 

Mucus : Mucus visible to the naked eye always indicates a 
catarrh of the mcus membrane of the intestine. Mucus occur- 
ring in solid fecal balls, in a fine equal division, usually means 
catarrh of the small intestine, it may also occur as a fine intimate 
mixture in thin stools in cases in which the large intestine is also 
affected. Large masses of mucus in more* or less thick shreds, 
or firm faeces covered with a layer of mucus usually indicate 
catarrh of the large intestine. 

Purulent Stools : A considerable collection of pure pus is 
not infrequently found in the stool, due to the rupture of a col- 
lection of pus into the bowel. This usually comes from some 
pelvic abscess or may come from the rupture of the pus from an 
appendicitis into the bowel. 

Usually this is easily recognized by the naked eye but if nec- 
essary and suspicious a portion should be examined microscopically. 

Dysenteric, syphilitic and carcinomatous ulcerations of the 
large intestine produce more or less pus depending upon their 
extent, and this may be in amount sufficient to be recognized 
with the unaided eye. 

Gall Stones: These come either from the gall-bladder or 
from the hepatic ducts and usually cause severe colic and often 
jaundice. After every case of severe abdominal pain, especially if 
followed by jaundice, the stools should be examined for gall-stones. 
This is best done by passing the stool through a sieve, if formed 
or mushy, breaking it up in water before passing through the sieve. 
Some conclusions may be drawn from the size and shape of the 
stone as to its source. Those from the gall-bladder are usually of 
some size and often present facets and many angles produced by 
other stones in the gall-bladder. Stones from the hepatic ducts 
are usually of small size, crumbling easily, and rarely shows facets 
or angles, usually being rounded. 

Portions oe Tissue : In intussusception, the entire intestine 
invaginates and if life be prolonged sufficiently, the invaginated 
portion may come away in the stool, effecting a spontaneous cure. 
Shreds of tissue in ulcerations, or bits of tissue from new forma- 
tions, as carcinomata, may be found in the stools. 



49 
ANIMAL PARASITES. 

Tape-worm: This worm consists of a very small head and 
neck and a ribbon of flat joints, often several metres in length. 
It inhabits exclusively the small intestine, clinging to the mucous 
membrane with its head and growing from above downward, the 
last joints dropping off as growth goes on. 

It can be recognized by a single joint, or it may be recog- 
nized by the passage of eg^s. 

There are three varieties of the tape-worm which are com- 
monly met with in the intestine. 

Taenia Solium: This is from 2 to 3 metres in length, the 
head, gray in color about the size of the head of a pin. The 
joints on the lower part of the worm are yellowish-white in color 
and measure about 10 mm in length by 5 to 6 mm in breadth, resem- 
bling a gourd seed. These ripe joints are thrown off frequently 
in the stools and from this peculiarity as well as the formation 
of a longitudinal canal (the uterus) we are able to differentiate it 
from the other varieties of tape-worm. This canal gives off as 
many as a dozen branches from its sides which subdivide like the 
branches of a tree. The eggs are round with a hard shell requir- 
ing a moderate magnifying power for their detection. The head 
when examined under a low power will show a circular row of 
hooks srurounded by four pigmented sucking discs or cups. 

Taenia Mediocaxellata grows to a length of 4 or 5 
metres. Its head is larger than that of taenia solium and has 
no zone of hooklets, only showing the four sucking cups which 
are larger and stronger than those of taenia solium. 

The ripe segments are passed by the stool and also wander 
from the anus independently, having a free movement of their 
own. They are slightly larger and thicker than those of taenia 
solium. 

Bothriocephalic latus is the largest of the tape- worms 
reaching a length of 7 to 8 metres. Its head is long, narrow, with 
two long narrow sucking cups. The joints are not passed singly 
but a large fragment comes away at long intervals. The eggs are 
quite large with a thin brownish capsule, provided with an open- 
ing on one end, covered by a cap of the same material. 

Ascaris Lumbricoldes : These are easily recognized by their 
resemblance to the common ground worm. They inhabit the small 
intestine, but have been found in vomited matters, in the ductus 
communis choledochus as the cause of jaundice, they are found in 
the stools and occasionally crawl out of the anus during sleep. 

Oxyuris Vermicularis: This is a small white worm resem- 
bling very much a bit of white thread, inhabiting especially the 
large intestine, caecum and rectum and occasionally wandering into 
the vagina. 

Trichina Spiralis: The worm is rarely seen in the intes- 
tinal contents but may occur there in the first stages of trichi- 



50 

nosis. They are only one-third the size of the oxyuris and must be 
examined for with a low power magnifying glass." In later stages 
of the disease the worms become encysted in the muscles. A 
small bit of the muscle may be cut out, teased and examined for 
the parasite. 

Ikfusokia of many kinds occur in the intestinal contents, 
usually associated with acute or chronic catarrh, &c. Most of them 
are of no clinical significance whatever. 

Amoeba Coli : This amoeba has been found to be the cause 
of a special form of dysentery. The suspected stool should be 
kept at body temperature and examined as soon as possible after 
its passage. A small bit of the white mucous is taken and placed 
on a clean, warm slide, covered with a thin cover-glass, pressed 
down to make a thin uuiform layer and examined under the 1-5 
objective. The amoeba is seen as a round body, freely movable, 
varying in diameter from 20 to 40 micromillimetres. It contains 
a small clear body in its center called the endosarc surrounded by 
a zone of more granular material the ectosarc. If kept warm and 
carefully watched the amoeba will be seen to throw out a pro- 
jection called a pseuedopodium and soon the entire body of the 
parasite will be seen to have moved into the psuedopodium. This 
parasite should always be looked for in the pus from abscesses of 
the liver, especially if at any time there had been symptoms of 
dysentery preceeding it. 

VEGETABLE PARASITES. 

Many forms of vegetable bacteria occur in the intestinal tract, 
whose identification can only be done by culture characteristics, 
Probably the most important bacillus for the physician is the 
bacillus of tuberculosis. This is stained for and examined as 
given under examination for sputum. If the bacillus is present 
in repeated examinations and is associated with symptoms of di- 
arrhoea, etc., the existence of intestinal tuberculosis may be in- 
ferred, though not definitely, as the bacilli may come from sputum 
which has been swallowed. In many of these cases there is no 
appearance of pus in the stool and a hap-hazard hunt is usually 
negative. In such cases the bacillus may be demonstrated by 
taking a small bit of the mucous from the mucous membrane or" 
the rectum and subjecting it to the stains for the tubercle 
bacillus. In all cases of chronic fistula-in-ano, with or without 
definite tuberculosis of other organs of the body, the pus from the 
fistula should be examined for the presence of the tubercle bac- 
illus. If present this will either call for non-interference if the 
disease is extensive and if not extensive will call for a more 
radical operation and a more guarded prognosis than the ordinary 
non-specific fistula-in-ano. 



PARASITES OF THE SKIN, 



VEGETABLE. 

Achorion Schonleinii: This fungus occurs in the root- 
sheaths, bulbs, hairs near the skin and in the crusts of the dif- 
ferent varieties of favus. The crusts or roots of the diseased 
hairs are placed in a little water or in dilute liquor potassae and 
allowed to macerate for a short time, after which they may be exa- 
mined without further preparation, or may be stained with aqueous 
methylene blue and examined under the 1-6 objective. It is seen 
to consist of dense masses of mycelium or threadlike material and 
a large number of round or oval bodies, the spores of the fungus. 
The threads or mycelium are jointed and the bodies between the 
joints are apparently divided into compartments. 

Trichophyton" Tonsurans: This fungus w T hich is found in 
all the different varieties of tinea or ringworm resembles the pre- 
ceding and is examined for in the same way. Usually it is less 
abundant, much less branched, shows fewer of the compartments 
spoken of under Achorion and the spores are less abundant. It 
is most abundant about the roots of the hair in the affected area 
and is most readily found by removing a few hairs from the 
affected area, softening the root and bulb with liquor potassas and 
examining under the 1-6 objective. 

Microsporon Furfur: The microsporon furfur is very easily 
found in the characteristic scales of tinea versicolor resembling 
quite closely the achorion but more prone to the development of 
spores, the latter being highly refractive and resembling minute 
globules of oil. 

ANIMAL. 

Practically in this climate the only animal parasite which 
needs the microscope for its detection is the itch mite or acarus 
scabiei. By close scrutiny in almost every case a burrow formed 
by the adult female may be found, the easiest place being on 
some covered portion of the body where it has not been altered 
by the scratching of the patient. A person with good eyesight 
can easily pass a fine cambric needle along and a little beyond 
the end of the burrow and uncover the insect. By the naked eye 
this can be recognized as a distinct yellowish wmite dot, quite 
distinct from the blackish excrement filling the rest of the burrow. 
The insect may be lifted from its burrow on the point of the 
needle and placed under the microscope, where its body is seen 
to be of an oval form, with a short projecting head. Its dorsum 
is convex and barred transversely. Its ventral surface is flat and 
is provided with eight small claws or legs. The males are 
smaller, resemble the female more or less but do not burrow in 
the skin. 



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